Required and Accurate Information in Directories; Reporting; Reimbursement for Reliance

  1. Law
  2. Georgia Code
  3. Insurance
  4. Accurate Provider Directories
  5. Required and Accurate Information in Directories; Reporting; Reimbursement for Reliance

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  1. The insurer shall include in both its online and print directories a clearly identifiable telephone number and either a dedicated e-mail address or a link to a dedicated webpage that covered persons or the general public may use to report to the insurer inaccurate information listed in the provider directory. Whenever an insurer receives such a report, it shall promptly investigate such report and no later than 30 days following receipt of such report either verify the accuracy of the information or update the information, as applicable.
    1. An insurer shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the insurer's provider directory and shall, no later than January 1, 2017, review and update the entire provider directory for each network plan offered. Thereafter, the insurer shall, at least annually, audit at least a reasonable sample size of its provider directories for accuracy, retain documentation of such an audit to be made available to the Commissioner upon request, and based on the results of such an audit, verify the accuracy of the information or update the information, if applicable.
    2. The insurer shall notify any provider in its network that has not submitted claims to the insurer or otherwise communicated intent to continue participation in the insurer's network within a 12 month period. Such notice shall be accomplished in accordance with provisions of the contract entered into between the insurer and the provider regarding notice, if applicable. If the insurer does not receive a response from the provider within 30 days of such notification confirming that the information regarding the provider is current and accurate or, as an alternative, updating any information, the insurer shall remove the provider from the network; provided, however, that prior to removal, the insurer may use any other available information or means to determine if the provider is still participating in the insurer's network, including any means delineated in the contract entered into between the insurer and the provider.
  3. The insurer shall report to the Commissioner, in accordance with timeframes and requirements established by the Commissioner:
    1. The number of reports received pursuant to subsection (a) of this Code section, the timeliness of the insurer's response, and the corrective actions taken; and
    2. All auditing reports conducted by the insurer pursuant to subsection (b) of this Code section.
  4. In circumstances where the Commissioner finds that a covered person reasonably relied upon materially inaccurate information contained in an insurer's provider directory, the Commissioner may require the insurer to provide coverage for all covered health care services provided to the covered person and to reimburse the covered person for any amount that he or she would have paid, had the services been delivered by an in-network provider under the insurer's network plan; provided, however, that the Commissioner shall take into consideration that insurers are relying on health care providers to report changes to their information prior to requiring any reimbursement to a covered person. Prior to requiring reimbursement in these circumstances, the Commissioner shall conclude that the services received by the insurer were covered services under the covered person's network plan. In such circumstances, the fact that the services were rendered or delivered by a noncontracting or out-of-network provider shall not be used as a basis to deny reimbursement to the covered person.

(Code 1981, §33-20C-3, enacted by Ga. L. 2016, p. 149, § 1/SB 302; Ga. L. 2018, p. 1112, § 33/SB 365.)

The 2018 amendment, effective May 8, 2018, part of an Act to revise, modernize, and correct the Code, revised punctuation in the first sentence of subsection (a).


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