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Ocga A 349208 Certification Of Managed Health Care Providers

(a)  Any health care provider or group of medical service providers may make written application to the board to become certified to provide managed care to injured employees for injuries and diseases compensable under this chapter.

(b)  Each application for certification shall be accompanied by a reasonable fee prescribed by the board.  A certificate is valid for such period as the board may prescribe unless sooner revoked or suspended.

(c) 
Application for certification shall be made in such form and manner and shall set forth such information regarding the proposed plan for providing services as the board may prescribe.  The information shall include, but not be limited to:

(1)  A list of the names of all individuals who will provide services under the managed care plan, together with appropriate evidence of compliance with any licensing or certification requirements for that individual to practice in this state;

(2)  A description of the times, places, and manner of providing services under the plan;

(3) 
A description of the times, places, and manner of providing other related optional services the applicants wish to provide; and

(4)  Satisfactory evidence of ability to comply with any financial requirements to ensure delivery of service in accordance with the plan which the board may prescribe.

(d)  The board shall certify health care providers or a group of medical service providers to provide managed care under a plan if the board finds that the plan:

(1)  Proposes to provide services that meet quality, continuity, and other treatment standards prescribed by the board and will provide all medical and health care services that may be required by this chapter in a manner that is timely, effective, and convenient for the employee;

(2)  Provides appropriate financial incentives to reduce service costs and utilization without sacrificing the quality of service;

(3)  Provides adequate methods of peer review, service utilization review, and dispute resolution to prevent inappropriate or excessive treatment, to exclude from participation in the plan those individuals who violate these treatment standards, and to provide for the resolution of such medical disputes as the board considers appropriate;

(4)  Provides a program involving cooperative efforts by the employees, the employer, and the managed care organization to promote consultative and other services that will contribute to workplace health and safety and early return to work for injured employees;

(5)  Provides a timely and accurate method of reporting to the board necessary information regarding medical and health care service costs and utilization to enable the board to determine the effectiveness of the plan; and

(6)  Complies with any other requirement the board determines is necessary to provide quality medical services and health care to injured workers at a reasonable cost.

(e)  The board shall refuse to certify or may revoke or suspend the certification of any health care provider or group of medical service providers to provide managed care if the members of the board find that:

(1)  The plan for providing medical or health care services fails to meet the requirements of this Code section; or

(2)  Service under the plan is not being provided in accordance with the terms of a certified plan.

(f)  Utilization review, quality assurance, and peer review activities pursuant to this Code section shall be subject to the review of the board or the board’s designated representatives.  Data generated by or received in connection with these activities, including written reports, notes, or records of any such activities, or of the board’s review thereof, shall be confidential and shall not be disclosed by the board except as considered necessary by the board in the administration of this chapter.  The board may report professional misconduct to an appropriate licensing authority.

(g)  No data generated by utilization review, quality assurance, or peer review activities pursuant to this Code section or the board’s review thereof shall be used in any action, suit, or proceeding except to the extent considered necessary by the board in the administration of this chapter.

(h)  A person participating in utilization review, quality assurance, or peer review activities pursuant to this Code section shall not be examined as to any communication made in the course of such activities or the findings thereof, nor shall any personnel be subject to an action for civil damage for affirmative actions taken or statements made in good faith.

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