| HB 732 - Patient's Right to Independent Review Act; enact |
First Reader Summary
A BILL to amend Chapter 1 of Title 51 of the Official Code of
Georgia Annotated, relating to general provisions regarding
torts, so as to establish a standard of care for certain entities
which administer benefits or review or adjust claims under a
managed care plan and provide for recovery for violations of that
standard; and for other purposes.
| Recorded Votes |
| Vote # |
SV99-340 |
PASSAGE AS AMENDED |
3/18/99 |
| Vote # |
HV99-1118 |
PASS |
03/09/99 |
| House |
Action |
Senate |
| 2/23/99 |
Read 1st Time |
3/10/99 |
| 2/24/99 |
Read 2nd Time |
3/17/99 |
| 3/3/99 |
Favorably Reported |
3/17/99 |
| Sub |
Committee Amend/Sub |
Am |
| 3/9/99 |
Read 3rd Time |
3/18/99 |
| 3/9/99 |
Passed/Adopted |
3/18/99 |
| CSFA |
Comm/Floor Amend/Sub |
CA |
| 3/22/99 |
Amend/Sub Agreed To |
|
| 3/26/99 |
Sent to Governor |
|
| 4/20/99 |
Signed by Governor |
|
| 281 |
Act/Veto Number |
|
| 7/1/99/9 |
Effective Date |
|
HB 732 HB 732/AP
H. B. No. 732 (AS PASSED HOUSE AND SENATE)
By: Representatives Smith of the 175th, Turnquest of the
73rd, Dukes of the 161st, Bordeaux of the 151st, Graves of
the 125th and others
A BILL TO BE ENTITLED
AN ACT
1- 1 To amend Chapter 1 of Title 51 of the Official Code of
1- 2 Georgia Annotated, relating to general provisions regarding
1- 3 torts, so as to establish a standard of care for certain
1- 4 entities which administer benefits or review or adjust
1- 5 claims under a managed care plan and provide for recovery
1- 6 for violations of that standard; to prohibit waivers,
1- 7 modifications, shifting, or delegation of liability; to
1- 8 provide conditions for maintaining certain causes of action;
1- 9 to provide for court orders and abatement of actions; to
1-10 provide that certain other liability is not created; to
1-11 amend Chapter 20A of Title 33 of the Official Code of
1-12 Georgia Annotated, the "Patient Protection Act of 1996,"
1-13 relating to managed care plans, so as to provide for a short
1-14 title; to provide for definitions; to provide certain
1-15 enrollees of managed care plans with an independent review
1-16 of plan determinations and provide for standards,
1-17 conditions, and procedures relating thereto; to provide for
1-18 duties, powers, and functions of the Health Planning Agency
1-19 with regard to such reviews and provide for certification of
1-20 independent review organizations; to provide for expert
1-21 reviewers and decisions thereof; to provide for costs and
1-22 expedited reviews; to provide for immunity from liability
1-23 and presumptions; to prohibit certain conflicts of interest;
1-24 to provide for quality assurance; to provide for
1-25 applicability; to provide for effective dates; to repeal
1-26 conflicting laws; and for other purposes.
1-27 BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:
1-28 SECTION 1.
1-29 Chapter 1 of Title 51 of the Official Code of Georgia
1-30 Annotated, relating to general provisions regarding torts,
1-31 is amended by adding at the end new Code sections to read as
1-32 follows:
-1-
2- 1 "51-1-48.
2- 2 (a) Any claim administrator, health care advisor, private
2- 3 review agent, or other person or entity which administers
2- 4 benefits or reviews or adjusts claims under a managed care
2- 5 plan shall exercise ordinary diligence to do so in a
2- 6 timely and appropriate manner in accordance with the
2- 7 practices and standards of the profession of the health
2- 8 care provider generally. Notwithstanding any other
2- 9 provision of law to the contrary, any injury or death to
2-10 an enrollee resulting from a want of such ordinary
2-11 diligence shall be a tort for which a recovery may be had
2-12 against the managed care entity offering such plan, but no
2-13 recovery shall be had for punitive damages for such tort.
2-14 (b) The provisions of this Code section may not be waived,
2-15 shifted, or modified by contract or agreement and
2-16 responsibility therefor shall be a duty which shall not be
2-17 delegated. Any effort to waive, modify, delegate, or
2-18 shift liability for a breach of the duty provided by this
2-19 Code section, through a contract for indemnification or
2-20 otherwise, shall be invalid.
2-21 (c) This Code section shall not create any liability on
2-22 the part of an employer of an enrollee or that employer's
2-23 employees, unless the employer is the enrollee's managed
2-24 care entity. This Code section shall not create any
2-25 liability on the part of an employee organization, a
2-26 voluntary employee beneficiary organization, or a similar
2-27 organization, unless such organization is the enrollee's
2-28 managed care entity and makes coverage determinations
2-29 under a managed care plan.
2-30 (d) As used in this Code section and in Code Section
2-31 51-1-49, the terms 'claim administrator,' 'enrollee,'
2-32 'health care advisor,' and 'private review agent,' shall
2-33 be defined as set forth in Chapter 46 of Title 33 except
2-34 that 'enrollee' shall include the enrollee's eligible
2-35 dependents; 'managed care entity' and 'managed care plan'
2-36 shall be defined as set forth in Code Section 33-20A-3;
2-37 and 'independent review' means a review pursuant to
2-38 Article 2 of Chapter 20A of Title 33, the 'Patient's Right
2-39 to Independent Review Act.'
2-40 51-1-49.
2-41 (a) No person may maintain a cause of action pursuant to
2-42 Code Section 51-1-48 unless the affected enrollee or the
2-43 enrollee's representative:
-2-
3- 1 (1) Has exhausted the grievance procedure provided for
3- 2 under Code Section 33-20A-5 and before instituting the
3- 3 action:
3- 4 (A) Gives written notice of intent to file suit to the
3- 5 managed care entity; and
3- 6 (B) Agrees to submit the claim to independent review
3- 7 if required under subsection (c) of this Code section;
3- 8 or
3- 9 (2) Has filed a pleading alleging in substance that:
3-10 (A) Harm to the enrollee has already occurred for
3-11 which the managed care entity may be liable; and
3-12 (B) The grievance procedure or independent review is
3-13 not timely or otherwise available or would not make
3-14 the enrollee whole,
3-15 in which case the court, upon motion by the managed care
3-16 entity, shall stay the action and order such grievance
3-17 procedure or independent review to be conducted and
3-18 exhausted.
3-19 (b) The notice required by paragraph (1) of subsection (a)
3-20 of this Code section must be delivered or mailed to the
3-21 managed care entity not fewer than 30 days before the
3-22 action is filed.
3-23 (c) The managed care entity receiving notice of intent to
3-24 file suit may obtain independent review of the claim, if
3-25 notice of a request for review is mailed or delivered to
3-26 the Health Planning Agency, or its successor agency, and
3-27 the affected enrollee within ten days of receipt of the
3-28 notice of intent to file suit."
3-29 SECTION 2.
3-30 Chapter 20A of Title 33 of the Official Code of Georgia
3-31 Annotated, the "Patient Protection Act of 1996," is amended
3-32 by designating Code Sections 33-20A-1 through 33-20A-10 as
3-33 Article 1 of said chapter and substituting "this article"
3-34 for "this chapter" and "This article" for "This chapter"
3-35 wherever such terms appear in the newly designated Article
3-36 1.
3-37 SECTION 3.
3-38 Said chapter is further amended by adding at the end thereof
3-39 a new article to read as follows:
-3-
4- 1 33-20A-30.
4- 2 This article shall be known and may be cited as the
4- 3 'Patient's Right to Independent Review Act.'
4- 4 33-20A-31.
4- 5 As used in this article:
4- 6 (1) 'Eligible enrollee' means a person who:
4- 7 (A) Is an enrollee or an eligible dependent of an
4- 8 enrollee of a managed care plan or was an enrollee or
4- 9 an eligible dependent of an enrollee of such plan at
4-10 the time of the request for treatment; and
4-11 (B) Seeks a treatment which reasonably appears to be a
4-12 covered service or benefit under the enrollee's
4-13 evidence of coverage; provided, however, that this
4-14 subparagraph shall not apply if the notice from a
4-15 managed care plan of the outcome of the grievance
4-16 procedure was that a treatment is experimental.
4-17 (2) 'Grievance procedure' means the grievance procedure
4-18 established pursuant to Code Section 33-20A-5.
4-19 (3) 'Independent review organization' means any
4-20 organization certified as such by the planning agency
4-21 under Code Section 33-20A-39.
4-22 (4) 'Medical and scientific evidence' means:
4-23 (A) Peer reviewed scientific studies published in or
4-24 accepted for publication by medical journals that meet
4-25 nationally recognized requirements for scientific
4-26 manuscripts and that submit most of their published
4-27 articles for review by experts who are not part of the
4-28 editorial staff;
4-29 (B) Peer reviewed literature, biomedical compendia,
4-30 and other medical literature that meet the criteria of
4-31 the National Institutes of Health's National Library
4-32 of Medicine for indexing in Index Medicus, Excerpta
4-33 Medicus (EMBASE), Medline, and MEDLARS data base or
4-34 Health Services Technology Assessment Research
4-35 (HSTAR);
4-36 (C) Medical journals recognized by the United States
4-37 secretary of health and human services, under Section
4-38 1861(t)(2) of the Social Security Act;
-4-
5- 1 (D) The following standard reference compendia: the
5- 2 American Hospital Formulary Service-Drug Information,
5- 3 the American Medical Association Drug Evaluation, the
5- 4 American Dental Association Accepted Dental
5- 5 Therapeutics, and the United States Pharmacopoeia-Drug
5- 6 Information; or
5- 7 (E) Findings, studies, or research conducted by or
5- 8 under the auspices of federal government agencies and
5- 9 nationally recognized federal research institutes
5-10 including the Federal Agency for Health Care Policy
5-11 and Research, National Institutes of Health, National
5-12 Cancer Institute, National Academy of Sciences, Health
5-13 Care Financing Administration, and any national board
5-14 recognized by the National Institutes of Health for
5-15 the purpose of evaluating the medical value of health
5-16 services.
5-17 (5) 'Medical necessity,' 'medically necessary care,' or
5-18 'medically necessary and appropriate' means care based
5-19 upon generally accepted medical practices in light of
5-20 conditions at the time of treatment which is:
5-21 (A) Appropriate and consistent with the diagnosis and
5-22 the omission of which could adversely affect or fail
5-23 to improve the eligible enrollee's condition;
5-24 (B) Compatible with the standards of acceptable
5-25 medical practice in the United States;
5-26 (C) Provided in a safe and appropriate setting given
5-27 the nature of the diagnosis and the severity of the
5-28 symptoms;
5-29 (D) Not provided solely for the convenience of the
5-30 eligible enrollee or the convenience of the health
5-31 care provider or hospital; and
5-32 (E) Not primarily custodial care, unless custodial
5-33 care is a covered service or benefit under the
5-34 eligible enrollee's evidence of coverage.
5-35 (6) 'Planning agency' means the Health Planning Agency
5-36 established under Chapter 6 of Title 31 or its successor
5-37 agency.
5-38 (7) 'Treatment' means a medical service, diagnosis,
5-39 procedure, therapy, drug, or device.
5-40 (8) Any term defined in Code Section 33-20A-3 shall have
5-41 the meaning provided for that term in Code Section
-5-
6- 1 33-20A-3 except that 'enrollee' shall include the
6- 2 enrollee's eligible dependents.
6- 3 33-20A-32.
6- 4 An eligible enrollee shall be entitled to appeal to an
6- 5 independent review organization when:
6- 6 (1) The eligible enrollee has received notice of an
6- 7 adverse outcome pursuant to a grievance procedure or the
6- 8 managed care entity has not complied with the
6- 9 requirements of Code Section 33-20A-5 with regard to
6-10 such procedure; or
6-11 (2) A managed care entity determines that a proposed
6-12 treatment is excluded as experimental under the managed
6-13 care plan, and all of the following criteria are met:
6-14 (A) The eligible enrollee has a terminal condition
6-15 that, according to the treating physician, has a
6-16 substantial probability of causing death within two
6-17 years from the date of the request for independent
6-18 review or the eligible enrollee's ability to regain or
6-19 maintain maximum function, as determined by the
6-20 treating physician, would be impaired by withholding
6-21 the experimental treatment;
6-22 (B) After exhaustion of standard treatment as provided
6-23 by the evidence of coverage or a finding that such
6-24 treatment would be of substantially lesser or of no
6-25 benefit, the eligible enrollee's treating physician
6-26 certifies that the eligible enrollee has a condition
6-27 for which standard treatment would not be medically
6-28 indicated for the eligible enrollee or for which there
6-29 is no standard treatment available under the evidence
6-30 of coverage of the eligible enrollee more beneficial
6-31 than the treatment proposed;
6-32 (C) The eligible enrollee's treating physician has
6-33 recommended and certified in writing treatment which
6-34 is likely to be more beneficial to the eligible
6-35 enrollee than any available standard treatment;
6-36 (D) The eligible enrollee has requested a treatment as
6-37 to which the eligible enrollee's treating physician,
6-38 who is a licensed, board certified or board eligible
6-39 physician qualified to practice in the area of
6-40 medicine appropriate to treat the eligible enrollee's
6-41 condition, has certified in writing that
6-42 scientifically valid studies using accepted protocols,
-6-
7- 1 such as control group or double-blind testing,
7- 2 published in peer reviewed literature, demonstrate
7- 3 that the proposed treatment is likely to be more
7- 4 beneficial for the eligible enrollee than available
7- 5 standard treatment; and
7- 6 (E) A specific treatment recommended would otherwise
7- 7 be included within the eligible enrollee's certificate
7- 8 of coverage, except for the determination by the
7- 9 managed care entity that such treatment is
7-10 experimental for a particular condition.
7-11 33-20A-33.
7-12 Except where required pursuant to Code Section 51-1-49, a
7-13 proposed treatment must require the expenditure of a
7-14 minimum of $500.00 to qualify for independent review.
7-15 33-20A-34.
7-16 (a) The parent or guardian of a minor who is an eligible
7-17 enrollee may act on behalf of the minor in requesting
7-18 independent review. The legal guardian or representative
7-19 of an incapacitated eligible enrollee shall be authorized
7-20 to act on behalf of the eligible enrollee in requesting
7-21 independent review. Except as provided in Code Section
7-22 51-1-49, independent review may not be requested by
7-23 persons other than the eligible enrollee or a person
7-24 acting on behalf of the eligible enrollee as provided in
7-25 this Code section.
7-26 (b) A managed care entity shall be required to pay the
7-27 full cost of applying for and obtaining the independent
7-28 review.
7-29 (c) The eligible enrollee and the managed care entity
7-30 shall cooperate with the independent review organization
7-31 to provide the information and documentation, including
7-32 executing necessary releases for medical records, which
7-33 are necessary for the independent review organization to
7-34 make a determination of the claim.
7-35 33-20A-35.
7-36 (a) In the event that the outcome of the grievance
7-37 procedure under Code Section 33-20A-5 is adverse to the
7-38 eligible enrollee, the managed care entity shall include
7-39 with the written notice of the outcome of the grievance
7-40 procedure a statement specifying that any request for
7-41 independent review must be made to the planning agency on
-7-
8- 1 forms developed by the planning agency, and such forms
8- 2 shall be included with the notification. Such statement
8- 3 shall be in simple, clear language in boldface type which
8- 4 is larger and bolder than any other typeface which is in
8- 5 the notice and in at least 14 point typeface.
8- 6 (b) An eligible enrollee must submit the written request
8- 7 for independent review to the planning agency.
8- 8 Instructions on how to request independent review shall be
8- 9 given to all eligible enrollees with the written notice
8-10 required under this Code section together with
8-11 instructions in simple, clear language as to what
8-12 information, documentation, and procedure are required for
8-13 independent review.
8-14 (c) Upon receipt of a completed form requesting
8-15 independent review as required by subsection (a) of this
8-16 Code section, the planning agency shall notify the
8-17 eligible enrollee of receipt and assign the request to an
8-18 independent review organization on a rotating basis
8-19 according to the date the request is received.
8-20 (d) Upon assigning a request for independent review to an
8-21 independent review organization, the planning agency shall
8-22 provide written notification of the name and address of
8-23 the assigned organization to both the requesting eligible
8-24 enrollee and the managed care entity.
8-25 (e) No managed care entity may be certified by the
8-26 Commissioner under Article 1 of this chapter unless the
8-27 entity agrees to pay the costs of independent review to
8-28 the independent review organization assigned by the
8-29 planning agency to conduct each review involving such
8-30 entity's eligible enrollees.
8-31 33-20A-36.
8-32 (a) Within three business days of receipt of notice from
8-33 the planning agency of assignment of the application for
8-34 determination to an independent review organization, the
8-35 managed care entity shall submit to that organization the
8-36 following:
8-37 (1) Any information submitted to the managed care entity
8-38 by the eligible enrollee in support of the eligible
8-39 enrollee's grievance procedure filing;
8-40 (2) A copy of the contract provisions or evidence of
8-41 coverage of the managed care plan; and
-8-
9- 1 (3) Any other relevant documents or information used by
9- 2 the managed care entity in determining the outcome of
9- 3 the eligible enrollee's grievance.
9- 4 Upon request, the managed care entity shall provide a copy
9- 5 of all documents required by this subsection, except for
9- 6 any proprietary or privileged information, to the eligible
9- 7 enrollee. The eligible enrollee may provide the
9- 8 independent review organization with any additional
9- 9 information the eligible enrollee deems relevant.
9-10 (b) The independent review organization shall request any
9-11 additional information required for the review from the
9-12 managed care entity and the eligible enrollee within five
9-13 business days of receipt of the documentation required
9-14 under this Code section. Any additional information
9-15 requested by the independent review organization shall be
9-16 submitted within five business days of receipt of the
9-17 request, or an explanation of why the additional
9-18 information is not being submitted shall be provided.
9-19 (c) Additional information obtained from the eligible
9-20 enrollee shall be transmitted to the managed care entity,
9-21 which may determine that such additional information
9-22 justifies a reconsideration of the outcome of the
9-23 grievance procedure. A decision by the managed care
9-24 entity to cover fully the treatment in question upon
9-25 reconsideration using such additional information shall
9-26 terminate independent review.
9-27 (d) The expert reviewer of the independent review
9-28 organization shall make a determination within 15 business
9-29 days after expiration of all time limits set forth in this
9-30 Code section, but such time limits may be extended or
9-31 shortened by mutual agreement between the eligible
9-32 enrollee and the managed care entity. The determination
9-33 shall be in writing and state the basis of the reviewer's
9-34 decision. A copy of the decision shall be delivered to
9-35 the managed care entity, the eligible enrollee, and the
9-36 planning agency by at least first-class mail.
9-37 (e) The independent review organization's decision shall
9-38 be based upon a review of the information and
9-39 documentation submitted to it.
9-40 (f) Information required or authorized to be provided
9-41 pursuant to this Code section may be provided by facsimile
9-42 transmission or other electronic transmission.
-9-
10- 1 33-20A-37.
10- 2 (a) A decision of the independent review organization in
10- 3 favor of the eligible enrollee shall be final and binding
10- 4 on the managed care entity and the appropriate relief
10- 5 shall be provided without delay. A managed care entity
10- 6 bound by such decision of an independent review
10- 7 organization shall not be liable pursuant to Code Section
10- 8 51-1-48 for abiding by such decision. Nothing in this Code
10- 9 section shall relieve the managed care entity from
10-10 liability for damages proximately caused by its
10-11 determination of the proposed treatment prior to such
10-12 decision.
10-13 (b) A determination by the independent review organization
10-14 in favor of a managed care entity shall create a
10-15 rebuttable presumption in any subsequent action that the
10-16 managed care entity's prior determination was appropriate
10-17 and shall constitute a medical record for purposes of Code
10-18 Section 24-7-8.
10-19 (c) In the event that, in the judgment of the treating
10-20 health care provider, the health condition of the enrollee
10-21 is such that following the provisions of Code Section
10-22 33-20A-36 would jeopardize the life or health of the
10-23 eligible enrollee or the eligible enrollee's ability to
10-24 regain maximum function, as determined by the treating
10-25 health care provider, an expedited review shall be
10-26 available. The expedited review process shall encompass
10-27 all elements enumerated in Code Sections 33-20A-36 and
10-28 33-20A-40; provided, however, that a decision by the
10-29 expert reviewer shall be rendered within 72 hours after
10-30 the expert reviewer's receipt of all available requested
10-31 documents.
10-32 33-20A-38.
10-33 Neither independent review organization nor its employees,
10-34 agents, or contractors shall be liable for damages arising
10-35 from determinations made pursuant to this article, unless
10-36 an act or omission thereof is made in bad faith or through
10-37 gross negligence, constitutes fraud or willful misconduct,
10-38 or demonstrates malice, wantonness, oppression, or that
10-39 entire want of care which would raise the presumption of
10-40 conscious indifference to the consequences.
-10-
11- 1 33-20A-39.
11- 2 (a) The planning agency shall certify independent review
11- 3 organizations that meet the requirements of this Code
11- 4 section and any regulations promulgated by the planning
11- 5 agency consistent with this article. The planning agency
11- 6 shall deem certified any independent review organization
11- 7 meeting standards developed for this purpose by an
11- 8 independent national accrediting organization. To qualify
11- 9 for certification, an independent review organization must
11-10 show the following:
11-11 (1) Expert reviewers assigned by the independent review
11-12 organization must be physicians or other appropriate
11-13 providers who meet the following minimum requirements:
11-14 (A) Are expert in the treatment of the medical
11-15 condition at issue and are knowledgeable about the
11-16 recommended treatment through actual clinical
11-17 experience;
11-18 (B) Hold a nonrestricted license issued by a state of
11-19 the United States and, for physicians, a current
11-20 certification by a recognized American medical
11-21 specialty board in the area or areas appropriate to
11-22 the subject of review; and
11-23 (C) Have no history of disciplinary action or
11-24 sanctions, including, but not limited to, loss of
11-25 staff privileges or participation restriction, taken
11-26 or pending by any hospital, government, or regulatory
11-27 body;
11-28 (2) The independent review organization shall not be a
11-29 subsidiary of, nor in any way owned or controlled by, a
11-30 health plan, a trade association of health plans, a
11-31 managed care entity, or a professional association of
11-32 health care providers; and
11-33 (3) The independent review organization shall submit to
11-34 the planning agency the following information upon
11-35 initial application for certification, and thereafter
11-36 within 30 days of any change to any of the following
11-37 information:
11-38 (A) The names of all owners of more than 5 percent of
11-39 any stock or options, if a publicly held organization;
11-40 (B) The names of all holders of bonds or notes in
11-41 excess of $100,000.00, if any;
-11-
12- 1 (C) The names of all corporations and organizations
12- 2 that the independent review organization controls or
12- 3 is affiliated with, and the nature and extent of any
12- 4 ownership or control, including the affiliated
12- 5 organization's type of business; and
12- 6 (D) The names of all directors, officers, and
12- 7 executives of the independent review organization, as
12- 8 well as a statement regarding any relationships the
12- 9 directors, officers, and executives may have with any
12-10 health care service plan, disability insurer, managed
12-11 care entity or organization, provider group, or board
12-12 or committee.
12-13 (b) Neither the independent review organization nor any
12-14 expert reviewer of the independent review organization may
12-15 have any material professional, familial, or financial
12-16 conflict of interest with any of the following:
12-17 (1) A managed care plan or entity being reviewed;
12-18 (2) Any officer, director, or management employee of a
12-19 managed care plan which is being reviewed;
12-20 (3) The physician, the physician's medical group, health
12-21 care provider, or the independent practice association
12-22 proposing a treatment under review;
12-23 (4) The institution at which a proposed treatment would
12-24 be provided;
12-25 (5) The eligible enrollee or the eligible enrollee's
12-26 representative; or
12-27 (6) The development or manufacture of the treatment
12-28 proposed for the eligible enrollee whose treatment is
12-29 under review.
12-30 (c) As used in subsection (b) of this Code section, the
12-31 term 'conflict of interest' shall not be interpreted to
12-32 include a contract under which an academic medical center
12-33 or other similar medical research center provides health
12-34 care services to eligible enrollees of a managed care
12-35 plan, except as subject to the requirement of paragraph
12-36 (4) of subsection (b) of this Code section; affiliations
12-37 which are limited to staff privileges at a health care
12-38 facility; or an expert reviewer's participation as a
12-39 contracting plan provider where the expert is affiliated
12-40 with an academic medical center or other similar medical
12-41 research center that is acting as an independent review
-12-
13- 1 organization under this article. An agreement to provide
13- 2 independent review for an eligible enrollee or managed
13- 3 care entity is not a conflict of interest under subsection
13- 4 (b) of this Code section.
13- 5 (d) The independent review organization shall have a
13- 6 quality assurance mechanism in place that ensures the
13- 7 timeliness and quality of the reviews, the qualifications
13- 8 and independence of the experts, and the confidentiality
13- 9 of medical records and review materials.
13-10 (e) The planning agency shall provide upon the request of
13-11 any interested person a copy of all nonproprietary
13-12 information filed with it pursuant to this article. The
13-13 planning agency shall provide at least quarterly a current
13-14 list of certified independent review organizations to all
13-15 managed care entities and to any interested persons.
13-16 33-20A-40.
13-17 (a) For the purposes of this article, in making a
13-18 determination as to whether a treatment is medically
13-19 necessary and appropriate, the expert reviewer shall use
13-20 the definition provided in paragraph (5) of Code Section
13-21 33-20A-31.
13-22 (b) For the purposes of this article, in making a
13-23 determination as to whether a treatment is experimental,
13-24 the expert reviewer shall determine:
13-25 (1) Whether such treatment has been approved by the
13-26 federal Food and Drug Administration; or
13-27 (2) Whether medical and scientific evidence demonstrates
13-28 that the expected benefits of the proposed treatment
13-29 would be greater than the benefits of any available
13-30 standard treatment and that the adverse risks of the
13-31 proposed treatment will not be substantially increased
13-32 over those of standard treatments.
13-33 For either determination, the expert reviewer shall apply
13-34 prudent professional practices and shall assure that at
13-35 least two documents of medical and scientific evidence
13-36 support the decision.
13-37 33-20A-41.
13-38 The planning agency shall provide necessary rules and
13-39 regulations for the implementation and operation of this
13-40 article."
-13-
14- 1 SECTION 4.
14- 2 For purposes of certifying independent review organizations
14- 3 by the Health Planning Agency, or its successor agency, this
14- 4 Act shall become effective upon its approval by the Governor
14- 5 or upon its becoming law without such approval. For all
14- 6 other purposes, this Act shall become effective on July 1,
14- 7 1999, and shall be applicable to any contract, policy, or
14- 8 other agreement of a managed care plan or health maintenance
14- 9 organization if such contract, policy, or agreement provides
14-10 for health care services or reimbursement therefor and is
14-11 issued, issued for delivery, delivered, or renewed on or
14-12 after July 1, 1999.
14-13 SECTION 5.
14-14 All laws and parts of laws in conflict with this Act are
14-15 repealed.
-14-
Clerk of the House
Robert E. Rivers, Jr., Clerk
Last Updated on 05/05/99
