Managed Care Patient's Rights
In 1999, the Georgia General Assembly passed House Bill 732, giving members of HMOs the right to appeal decisions that deny coverage for medical services.
Who is eligible?
To be eligible for an independent review, you must meet the following criteria unless otherwise provided in the statute:
- You must have already followed the grievance procedure of your managed care plan, and treatment is still denied.
- You must have spent at least $500 on the treatment.
- The treatment should appear to be a reasonably covered service.
You are also eligible if a managed care company says that a proposed treatment is excluded under its plan because it is experimental. You must meet ALL of the following criteria:
- According to the treating physician, the patient is expected to die within two years, or the patient cannot regain his or her health or stay healthy without the experimental treatment.
- The patient has undergone all standard treatments covered under the health plan.
- The physician believes that the patient has a condition that does not need standard treatment, or a better treatment is not available under coverage.
- The physician has recommended treatment that will help the patient more than any standard treatment.
- The specific treatment would be included in coverage unless it is considered experimental for a particular condition.
How do I apply for an Independent Review?
To ask for an independent review, write to the Department of Community Health's Division of Health Planning. Please include the following information:
- The patient's name
- The name of the person acting on the patient's behalf (if the patient is a minor or incapacitated)
- The patient's address and phone number
- The name of the Health Benefit Plan and the policy number
- A copy of the notice you received from the managed care company that denied the treatment
Send your request to:
Attention: Independent Review Requests
Office of General Counsel/Division of Health Planning
Georgia Department of Community Health
2 Peachtree Street, NW; 5th Floor
Atlanta, GA 30303-3142
If you have questions regarding Managed Care Patient's Rights please call (404) 656-0409.
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For your convenience, you may download the following form and fill in the above information on it:
What happens to my request?
The Division of Health Planning will randomly assign your case to an independent review organization. It will give you the name and address of the review organization to which your case has been assigned. You or your managed care company may need to provide more information to the review organization. You have five days to send this information, but if you need more time, you can ask for an extension of up to 10 working days.
An expert reviewer will review your case and either approve or deny the treatment. The organization will mail a copy of the decision letter to you, the Division of Health Planning and your managed care company.
How long does it take for the reviewer to make a decision?
The reviewer will make a decision within 15 working days after the "additional information" deadline. However, the time period may change if you, your representative and the managed care company all agree to it.
If the health care provider believes that the review process would jeopardize the patient's health, the reviewer can make a decision within 72 hours after he or she receives all the information.
Learn more about IROs:
Quarterly IRO Notice - Updated 12/18/19