Definitions

  1. Law
  2. Georgia Code
  3. Insurance
  4. Managed Health Care Plans
  5. Managed Health Care Plans
  6. Definitions

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As used in this article, the term:

  1. "Agent" shall not include an agent or agency as defined in Code Section 33-23-1.
  2. "Carrier" means an accident and sickness insurer, fraternal benefit society, health care corporation, health maintenance organization, provider sponsored health care corporation, or any similar entity and any self-insured health benefit plan not subject to the exclusive jurisdiction of the federal Employee Retirement Income Security Act of 1974, 29 U.S.C. Section 1001, et seq., which entity provides for the financing or delivery of health care services through a health benefit plan, or the plan administrator of any health benefit plan established pursuant to Article 1 of Chapter 18 of Title 45.
  3. "Claimant" means any provider, facility, or individual making a claim under a health benefit plan on behalf of an enrollee.
  4. "Enrollee" has the same meaning as provided in Code Section 33-20A-3.
  5. "Health benefit plan" has the same meaning as provided in Code Section 33-24-59.5.
  6. "Physician contract" means any contract between a physician and a carrier or a carrier's network, physician panel, intermediary, or representative providing the terms under which the physician agrees to provide health care services to an enrollee pursuant to a health benefit plan.
  7. "Postpayment audit" means an investigation by a health benefit plan, carrier, insurer, or panel, or agent thereof, of whether a claim was properly paid to a claimant.
  8. "Retroactive denial of a previously paid claim" or "retroactive denial of payment" means any attempt by a carrier retroactively to collect payments already made to a claimant with respect to a claim, or any portion thereof, by requiring repayment of such payments, by reducing other payments owed to the claimant, by withholding or setting off against future payments, or in any other manner reducing or affecting the future claim payments to the claimant.

(Code 1981, §33-20A-60, enacted by Ga. L. 2002, p. 441, § 9; Ga. L. 2003, p. 140, § 33; Ga. L. 2019, p. 337, § 1-90/SB 132.)

The 2019 amendment, effective July 1, 2019, deleted "as used in this article" preceding "shall not include" in paragraph (1); deleted "hospital service corporation, medical service corporation," following "fraternal benefit society," in paragraph (2); deleted former paragraph (4), which read: " 'Commissioner' means the Commissioner of Insurance."; redesignated former paragraphs (5) through (9) as present paragraphs (4) through (8), respectively; and, in paragraph (8), deleted "currently" following "other payments".

Editor's notes.

- For short title and applicability, see the Editor's notes at the beginning of this article.

Law reviews.

- For note on the 2002 enactment of this Code section, see 19 Ga. St. U.L. Rev. 220 (2002).


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