Ga. Comp. R. & Regs. R. 120-2-83-.02 - Definitions

(a) For purposes of this Regulation Chapter and O.C.G.A. § 33- 20A-9.1:

(1) "Accepted provider" shall mean a provider that has been nominated by an enrollee and either accepted by a managed care entity which has chosen not to credential nominated providers or accepted by a managed care entity following credentialing in accordance with Rule 120-2-83-.05.

(2) "Deselected provider" shall mean a provider that has been nominated by an enrollee and provisionally accepted by the managed care entity, but later disapproved for reimbursement because the provider fails to meet one of the criteria for participation set forth in O.C.G.A. § 33-20A-9.1(c).

(3) "Enrollee" shall mean an enrollee of a managed care entity required to offer the consumer choice option pursuant to O.C.G.A. § 33- 20A-9.1(b).

(4) "Nominated provider" shall mean an out of network provider nominated by an enrollee.

(5) "Option" shall mean the consumer choice option as defined in O.C.G.A. § 33-20A-9.1(b).

(6) "Managed Care Entity" shall mean any entity identified pursuant to O.C.G.A. § 33-20A-3(6) and required to offer the option pursuant to O.C.G.A. § 33-20A-9.1(c).

(7) "Provider" shall mean a health care provider as defined in O.C.G.A. § 33-20A-3(3) or a hospital.

(8) "Provisionally accepted provider" shall mean a provider that has been nominated by an enrollee and provisionally accepted by the managed care entity upon receipt of the nominating form.

(9) "Rejected provider" shall mean a provider that has been nominated by an enrollee and disapproved because the provider fails to meet one of the criteria for participation set forth in O.C.G.A. § 33- 20A-9.1(c) by a managed care entity which has chosen not to credential nominated providers.

(10) "Similarly situated provider" shall mean an in network provider located in the same geographic area and providing the same or similar services as the nominated provider.

Notes

Ga. Comp. R. & Regs. R. 120-2-83-.02

O.C.G.A. Secs. 33-2-9, 33-20A-9.1.

Original Rule entitled "Definitions" was f. as ER 120-2-83- 0.10-.02. F. and eff. on November 24, 1999, the date of adoption, to remain in effect for 120 days or until the effective date of a permanent Rule covering the same subject matter is adopted, as specified by the Agency. Amended: Permanent Rule of same title adopted. F. Mar. 3, 2000; eff. Mar. 23, 2000.