Utilization Review Licensing in Georgia

Utilization review licenses and certificates are typically issued for organizations conducting either medical or workers’ compensation reviews. This guide contains information about utilization review in Georgia. For assistance with licensing, please contact us to learn about our software and managed license services.

Georgia Independent Review Organization Certification

Type of Review:

Medical Utilization Review

Agency:Georgia Department of Community Health
Law:

O.C.G.A. § 33-20A-39

Foreign Qualification is Prerequisite:Yes
Fact Checked:2/5/21

Initial Registration

Form:

Application for Certification as an IRO

Agency Fee:

$500

Required Attachments:
  • A copy of the organization's independent review plan
  • A written quality assurance mechanism in place that ensures the timeliness and quality of the reviews, the qualifications and independence of the expert reviewers, and the confidentiality of medical records and review materials.
  • Copies of policies and any procedures ensuring compliance with all applicable state and
    federal laws and with the Rules to protect confidentiality of medical records and personal information.
  • A listing of the number, type, and minimum qualifications of the personnel either employed or under contract to perform the independent review.
  • A copy of written procedures used to determine whether physicians or other health care providers utilized by the independent review organization describe the personnel and the accrediting policies and procedures of the applicant.
  • A completed profile for each expert reviewer and provider as outlined in the Rules.
  • Biographical information about officers, directors and staff as detailed on the application.
  • A copy of the most recent by-laws and articles of incorporation for the legal applicant.
  • Evidence of the applicant's authorization to conduct business in that state of Georgia.
  • A description of the existing or proposed organization and provide a copy of the organizational chart.
  • A chart showing contractual arrangements of the independent review system.
  • The names of each stockholder or owner of more than five percent of any stock or options.
  • The name and type of business of each corporation or other organization that the applicant controls or is affiliated with and the nature and extent of the affiliation or control. Also provide a chart or list clearly identifying the relationship between the applicant and any affiliates.
  • A list of any currently outstanding loans or contracts to provide services between the applicant and any affiliates or any officer of its affiliates.
  • The names of any predecessor affiliates and /or companies, including trade names.
Fact Checked:2/5/21

Registration Renewal

Form:

Renewal of Certificate of Registration for IRO

Agency Fee:

$250

Due:

Annually at least 90 days prior to the anniversary of registration.

Georgia Private Review Agent Certification

Type of Review:

Medical Utilization Review

Agency:Georgia Office of Insurance and Safety Fire Commissioner
Fact Checked:7/26/18

Initial Registration

Form:

Application for Certification as a Private Review Agent

Agency Fee:

$1,000

Notarize:Required
Required Attachments:
  • Certified copy of entity formation documents including amendments
  • Copy of bylaws, rules and regulations or similar documents regulating the affairs of the private review agent certified by the principal partners or the president and secretary and containing the corporate seal.
  • Names, addresses, and titles of positions held by individuals who are responsible for the conduct of the affairs of the private review agent in Georgia.
  • A copy of the biographical affidavit for each person listed as responsible for the conduct of the affairs of the private review agent.
  • If using a DBA, a certified copy of the recorded application received from the Clerk of the Superior Court in the county where doing business.
  • Some additional attachments as noted in the Checklist of Application Documents for Initial Certification of Private Review Agents
Fact Checked:2/5/21

Registration Renewal

Form:

Application for Certification as a Private Review Agent (Renewal)

Agency Fee:

$500

Due:

Biennially by the date of issuance.

Notarize:Required
Fact Checked:2/5/21

Supplemental Reporting
Annual Report

Form:

Annual Report Information for Utilization Review Activities

Agency Fee:

$0

Due:

Annually by March 1.

Law:

GAC § 120-2-58-.07

Fact Checked:2/5/21

Supplemental Reporting
Complaint Report

Agency Fee:

$0

Due:

Annually by March 1.

Law:

GAC § 120-2-58-.07

Fact Checked:2/5/21

Georgia Resources

Adverse Determination - When a health care plan or utilization review program decides that a medical treatment or service is not necessary.

Concurrent Review - Utilization review that is conducted during a patient’s course of treatment.

External Review - When an independent review organization is consulted to appeal an insurance company’s adverse determination.

Independent Review Organization (IRO) - Unbiased third-parties that conduct utilization review.

Prospective Review - Utilization review that occurs prior to treatment.

Retrospective Review - Utilization review that occurs after treatment and often after payment.

Utilization Review - A system for evaluating the medical necessity, efficiency, and appropriateness of medical services.

Utilization Review Agent (URA) - An entity that conducts utilization review.

Utilization Review Plan - A document of the procedures used during utilization review.

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