Coverage of Outpatient Surgery

  1. Law
  2. Georgia Code
  3. Insurance
  4. Insurance Generally
  5. General Provisions
  6. Coverage of Outpatient Surgery

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  1. As used in this Code section, the term:
    1. "Anesthetic" means an agent that produces insensibility to pain or touch. According to their action, such anesthetics are subdivided into the categories of general and local anesthetics.
    2. "Charges for facility services" means charges for such items as drugs and biologicals administered at the facility, trays, bandages, and casts which are furnished incidentally to a physician's services and which are commonly furnished in a physician's office.
    3. "General anesthetic" means an anesthetic that is complete and affects the entire body causing loss of consciousness when the anesthetic acts upon the brain. Such anesthetics are usually administered intravenously or through inhalation.
    4. "Licensed medical practitioner" means a medical practitioner who is currently licensed to practice medicine under Chapter 34 or 35 of Title 43 and who has agreed to submit to review by a Professional Standards Review Organization (PSRO) established, conditionally or otherwise, pursuant to Part B of Title XI of the Social Security Act (42 U.S.C. Section 1320c, et seq.), or by a medical care foundation or other recognized peer review organization, and who is approved to perform the covered procedures under a local anesthetic at an accredited hospital located within the area where the procedures are performed.
    5. "Local anesthetic" means an anesthetic affecting a local area only, the anesthetic operating upon the nerves or nerve tracts.
    6. "Medical emergency" means the sudden and unexpected onset of a condition with severe symptoms, requiring medical care which is secured immediately after the onset or within 72 hours after the onset of symptoms. The illness or condition as finally diagnosed must be one which normally would require immediate medical, not surgical, care. Sudden, unexpected, severe medical conditions or symptoms are those which are or which give evidence of being life threatening. Previously diagnosed chronic conditions in which subacute symptoms have existed over a period of time shall not be included in the definition of medical emergency unless symptoms suddenly become so severe as to require immediate medical aid. Provided they meet the requirements of this definition, conditions such as the following will qualify as medical emergencies: appendicitis, acute asthma, breathing difficulties or shortness of breath, severe bronchitis, severe onset of bursitis, severe chest pain, choking, coma, convulsions or seizures, cystitis, dermatitis or hives (resulting from internal or unknown causes), diabetic coma, severe diarrhea, drug reaction, epistaxis (nosebleed), fainting, severe fecal impaction, food poisoning, frostbite, acute attack of gall bladder, gastritis, acute gastrointestinal conditions, severe headache, suspected heart attack, hemorrhage, hysteria, insertion of catheter (for acute retention), insulin shock (overdose), kidney stone, maternity complications such as a suspected miscarriage (if policy covers maternity), sudden or severe onset of pain, pleurisy, pneumonitis, poisoning (including overdoses), pyelitis, pyelonephritis, shock, cerebral or cardiac spasms, spontaneous pneumothorax, severe stomach pains, strangulated hernia, stroke, sunstroke, swollen ring finger, tachycardia, thrombosis or phlebitis, unconsciousness, acute urinary retention, sudden onset of vision loss, or severe vomiting.
    7. "Professional fees" means charges for identifiable professional services rendered by a physician to a patient in person, which services contribute either to the diagnosis of the condition or the treatment of the patient.
  2. Every insurer authorized to issue accident and sickness benefit plans, policies, or contracts shall be required to make available, as an optional endorsement to all such policies that provide coverage for medical or surgical procedures which are required to be performed on an inpatient basis, an endorsement which provides at least the following coverages:
    1. Coverage which provides reimbursement for any covered surgical procedures performed on an outpatient basis when such procedures are performed by a licensed medical practitioner operating with the use of local anesthetic at a licensed outpatient surgical facility affiliated with a licensed hospital, at a licensed freestanding surgical facility, at a surgical facility operated by a health maintenance organization, or at the office of a licensed medical practitioner; and
    2. Coverage which provides reimbursement for medical or surgical procedures performed on an outpatient basis in the case of a medical emergency.
  3. All payments made under the coverages provided for in this Code section shall be made in accordance with the schedule of benefits contained in the policy, if applicable, or in accordance with the usual, customary, and reasonable professional fees and charges for facility services furnished in connection with such procedures.
  4. This Code section shall also apply to policies or contracts issued by a health care plan, a health maintenance organization, a fraternal benefit society, or any other similar entity.
  5. The requirements of this Code section with respect to a group or blanket accident and sickness insurance benefit plan, policy, or contract shall be satisfied if the coverage specified in paragraphs (1) and (2) of subsection (b) of this Code section is made available to the master policyholder of such plan, policy, or contract. Nothing in this Code section shall be construed to require the group insurer, health care plan, health maintenance organization, or master policyholder to provide or to make available such coverage to any certificate holder insured under such group policy, plan, or contract.
  6. Nothing in this Code section shall be construed to prohibit an insurer, health care plan, or other person issuing any similar accident and sickness insurance benefit plan, policy, or contract from issuing or continuing to issue an accident and sickness insurance benefit plan, policy, or contract which provides benefits greater than the minimum benefits required to be made available under this Code section or from issuing any such plans, policies, or contracts which provide benefits which are generally more favorable to the insured than those required to be made available under this Code section.

(Code 1933, § 56-2447, enacted by Ga. L. 1981, p. 991, § 1; Ga. L. 2017, p. 164, § 23/HB 127; Ga. L. 2020, p. 493, § 33/SB 429.)

The 2020 amendment, effective July 29, 2020, part of an Act to revise, modernize, and correct the Code, revised punctuation in paragraph (a)(4).

Cross references.

- Contents of individual accident and sickness insurance policies, T. 33, C. 29.

Contents of group or blanket accident and sickness insurance, T. 33, C. 30.

Code Commission notes.

- Pursuant to Code Section 28-9-5, in 1996, "Section" was inserted following "42 U.S.C." in paragraph (a)(4).

Law reviews.

- For article surveying developments in Georgia insurance law from mid-1980 through mid-1981, see 33 Mercer L. Rev. 143 (1981).

RESEARCH REFERENCES

Am. Jur. 2d.

- 43 Am. Jur. 2d, Insurance, § 540 et seq. 44 Am. Jur. 2d, Insurance, § 972 et seq.

C.J.S.

- 44 C.J.S., Insurance, §§ 573, 580 et seq., 631. 46 C.J.S., Insurance, § 1234 et seq. 46A C.J.S., Insurance, § 1783.


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