Ga. Comp. R. & Regs. R. 120-2-80-.02 - Definitions

Definitions under this Regulation Chapter shall have the meaning as set forth in the Georgia Insurance Code or the Rules and Regulations of the Office of Commissioner of Insurance, unless indicated below:

(a) "Appeal" shall mean a formal request, either orally, or in writing or by electronic transmission, to reconsider a determination not to certify an admission, extension of stay, or other health care service or procedure, and shall include both formal standard appeals and expedited appeals.

(b) "Complaint" shall mean a communication from the enrollee or member either orally, in writing or by electronic transmission concerning dissatisfaction by the enrollee or member with the health plan or its providers.

(c) "Grievance Procedure" shall mean a hearing provided to the enrollee, pursuant to O.C.G.A. § 33-20A-5(3)(B)(ii), regarding denial of payment in whole or in part for a health care service, treatment or claim, following exhaustion of all standard appeals requirements contained in O.C.G.A. Title 33, Chapter 46 or the Rules and Regulations of the Office of Commissioner of Insurance Chapter 120-2-58.

(d) "Managed Care Contractor" shall have the meaning set forth at O.C.G.A. § 33-20A-3(5) and shall include entities unaffiliated with a managed care entity providing network administrative, credentialling, utilization review or medical management services for the operation of one or more managed care plans.

(e) "Managed Care Entity" shall have the meaning set forth at § 33-20A-3(6) and shall include all insurers, health maintenance organizations, health care corporations, multiple employer welfare arrangements, or other entities which are subject to licensure by the Commissioner.

(f) "Stabilize", with respect to an emergency medical condition, shall mean to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual to or from a facility.

Notes

Ga. Comp. R. & Regs. R. 120-2-80-.02

O.C.G.A. Secs. 33-2-9, 33-20A-2, 33-20A-4, 33-20A-5.

Original Rule entitled "Definitions" adopted. F. Mar. 20, 1998; eff. Apr. 9, 1998.