Ga. Comp. R. & Regs. R. 120-2-83-.04 - Provider Nomination
(a)
Managed care entities shall create, and make readily available to nominated
providers, a nomination package which shall include, if applicable:
(1) Information regarding credentialing
procedures pursuant to Rule
120-2-83-.05. This includes, but is
not limited to, all forms required to be completed by the provider for the
purpose of credentialing; and
(2) A
compensation schedule specific to the nominated provider's area of
practice.
(b) Managed
care entities shall accept the nomination form referenced in Rule
120-2-83-.03(a) by
any means that evidences the date and time of receipt.
(c) Submission of the nomination form by the
enrollee shall not constitute acceptance of the nominated provider by the
managed care entity.
(d) Within
three (3) business days of receipt of the nomination form by the insurer, the
managed care entity shall provide notice in writing, to the provider and the
enrollee, of the provisional acceptance (in the case of managed care entities
which will implement a credentialing process in accordance with Rule
120-2-83-.05), final acceptance (in
the case of managed care entities which choose not to implement a credentialing
process in accordance with Rule
120-2-83-.05), or the rejection of
the nominated provider. In addition, the managed care entity shall make a good
faith effort to provide the notice required by this paragraph by facsimile
where practicable.
(e) For
deselected or rejected providers, the notice referred to in paragraph (d) shall
contain specific statutory, medical, professional or ethical reasons for
deselection or rejection. The provider may not be re-nominated by the enrollee
unless the nomination form contains materially different information as
determined by the provider or the managed care entity.
(f) Nothing in this Rule shall be construed
to limit the enrollee's right to emergency care as set forth in O.C.G.A.
§§
33-20A-3 and 33- 20A-9.
(g) Accepted or provisionally accepted
providers and enrollees shall be required to adhere to generally accepted rules
of the managed care entity.
(h)
Accepted or provisionally accepted providers shall be reimbursed at the average
contractual rate paid to similarly situated providers and such rates may differ
from plan to plan offered by a managed care entity.
(i) If a nominated provider will not be
providing services at a hospital within the managed care entity's network, the
enrollee must submit an additional nomination form for the hospital where
services will be provided. Managed care entities shall include information
regarding this requirement with the material supplied pursuant to Rule
120-2-83-.03(a).
Nothing in this Rule shall require a provider to perform services only at
hospitals within the managed care entity's network. Pursuant to O.C.G.A. §
33-20A-9.1(c)(1)(d),
out of network hospitals must meet all other reasonable criteria as required by
the managed care plan of in network hospitals.
(j) Where a managed care entity provisionally
accepts a nominated provider and then later deselects that provider based on
the credentialing process in accordance with Rule
120-2-83-.05, the managed care
entity is responsible for payment for covered services provided during the
credentialing review period and before notice of the deselection of the
nominated provider is received by the enrollee and the provider.
(k) Nothing in this Rule shall prohibit a
managed care entity from implementing alternate measures which are more
beneficial to the enrollee as agreed to by the enrollee and managed care
entity, providing the minimum requirements of this Rule are met.
Notes
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