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State guide

Georgia

Pick the kind of plan you have to see who to call first. Georgia can only help with plans it regulates.

On this page 7

Which plan do you have? Who to call first, by coverage

  • Your employer pays claims itself

    Georgia usually cannot help with these plans. Call the Employee Benefits Security Administration.

    Call 1-866-444-3272

  • Insurance you buy, or an employer plan bought from an insurer

    Call Georgia Office of Commissioner of Insurance and Safety Fire, Consumer Services Division. See the at-a-glance box.

    Call (404) 656-2070

  • Medicaid or children's coverage

    Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in Georgia.

    Medicaid in Georgia

  • Medicare

    Georgia SHIP (State Health Insurance Assistance Program), Georgia Department of Human Services Division of Aging Services gives free counseling. Or call 1-800-MEDICARE.

    Call 1-866-552-4464 1-800-633-4227

The short version for Georgia

Georgia has two routes to an outside review. People in managed care plans can ask the state insurance commissioner's office for an independent review under a state law, at no cost, and other plans use the federal external review process. Georgia has no separate consumer assistance program, so the insurance commissioner's Consumer Services Division is the main place to get help, and the state has its own surprise billing, step therapy and mental health parity laws.

At a glance: independent review for plans Georgia regulates

This box is for insurance you buy, or an employer plan bought from an insurer. It is not for Medicaid, Medicare or a plan your employer funds itself.

Main regulator
Georgia Office of Commissioner of Insurance and Safety Fire, Consumer Services Division · (404) 656-2070; toll-free (800) 656-2298
Independent review
A state process for some plans and the federal process for others (Independent review (Georgia's Patient's Right to Independent Review Act, for managed care plans) and federal external review (other plans))
Deadline to request it
State independent review: the state rules loaded set no filing deadline, so use any date in your denial letter and file promptly. Federal external review: 4 months after the date you receive the final denial notice.
Cost
None. Under the state process the managed care plan pays the full cost; the HHS-administered federal process is free (an insurer-hired review organization may charge no more than $25)
Decision time
State process: the expert reviewer decides within 15 working days after the deadlines for added information pass. Federal process: no later than 45 days after the request is received; fast track: 72 hours (state process: within 72 hours after the reviewer receives all requested documents)

Your own notice states the deadline and process for your plan, and controls if it differs. Plans your state does not regulate (for example job-based plans the employer funds itself) follow federal rules; see who regulates your plan.

Who regulates health plans

Georgia does not give an insurance-card tip. The Consumer Services Division says it has no jurisdiction over self-insured employer plans and union health and welfare plans, federal employees' health insurance, Medicare and Medicare HMOs, Medicaid, military insurance, the State of Georgia employees' health plan, the University System of Georgia plan, and policies purchased in another state (it says HMO members should call, because HMO policies may be an exception).

Independent (external) review

Process
A state process for some plans and the federal process for others. Run by State process: the Office of Commissioner of Insurance and Safety Fire, Administrative Procedure Division, which assigns a certified independent review organization. Federal process: MAXIMUS Federal Services for the U.S. Department of Health and Human Services (HHS), or a review organization hired by your insurer.
Where you file
either
How
Your final denial letter must say which process applies and include the request forms. For the state process, send a written request with your name and address and a copy of the plan's final grievance decision to: Attn: Administrative Procedure Department, Georgia Office of Commissioner of Insurance and Safety Fire, 2 Martin Luther King Jr. Drive, West Tower, Suite 704, Atlanta, GA 30334. For the federal process, file on the MAXIMUS secure website or call 1-888-866-6205 for a form.
Which denials qualify
State process: an unfavorable result from your managed care plan's grievance procedure (or the plan missing its grievance deadlines) for treatment costing at least $500, and treatment the plan excludes as experimental when you have a terminal or function-threatening condition and your physician certifies the treatment. Federal process: denials involving medical judgment, experimental or investigational treatment, and coverage cancelled for alleged false or incomplete information.
Appeal to the plan first?
Yes. The state process requires an unfavorable outcome from the plan's grievance procedure, unless the plan failed to follow that procedure, for example by not answering within 60 days (30 days if the care has not been given yet, 72 hours in urgent cases).

Official page

General rules and what to send: how external review works, how to request it.

Medicare and Medicaid in Georgia

Medicare counseling
Georgia SHIP (State Health Insurance Assistance Program), Georgia Department of Human Services Division of Aging Services · 1-866-552-4464 (select option 4) . Free help with Medicare appeals.
Medicaid agency
Georgia Department of Community Health (Georgia Medicaid); eligibility hearings are requested through the Division of Family and Children Services
Fair hearing deadline
Eligibility decisions: you must ask in writing within 30 days of the date of the notice. Decisions by a Medicaid health plan: plan handbooks say you must ask for a State Fair Hearing within 120 days of the date on the plan's final appeal decision letter. Your notice states the deadline that applies to you.
Good to know
If you are in a Medicaid health plan you must appeal to the plan first (within 60 days of the denial notice) and finish that appeal before asking for a State Fair Hearing. To keep services going during the hearing, one plan's member page says to ask in writing within 10 calendar days of the appeal decision notice; you may have to pay for that care if you lose. Hearings are held by an administrative law judge at the Office of State Administrative Hearings.

Medicaid appeals page How Medicaid appeals work

State laws that can help

State laws usually reach only plans your state regulates. They often do not reach job-based plans the employer funds itself.

Sources and what we could not confirm

Read from official pages on . Phone numbers and deadlines change; check the official page before you rely on one.

  1. Affordable Care Act: Working with States to Protect Consumers (State External Appeals Review Processes), Centers for Medicare & Medicaid Services
  2. External review, HealthCare.gov
  3. Georgia Consumer Assistance, Centers for Medicare & Medicaid Services
  4. File a Consumer Insurance Complaint, Georgia Office of Commissioner of Insurance and Safety Fire
  5. Health, Georgia Office of Commissioner of Insurance and Safety Fire
  6. Managed Care Patient's Rights, Georgia Department of Community Health
  7. Georgia Rules chapter 120-2-111, Patient's Right to Independent Review
  8. Georgia SHIP, Georgia Division of Aging Services
  9. Appendix B Hearings, Georgia Medicaid policy manual (Division of Family and Children Services)
  10. Enrollee Handbook (WellCare), hosted by Georgia Medicaid
  11. Filing an Appeal, Peach State Health Plan
  12. House Bill 63 (2019), signed legislation, Office of the Governor
  13. O.C.G.A. section 33-20E-4, Payment for emergency medical services
  14. O.C.G.A. section 33-1-27, mental health parity
  15. Surprise billing arbitration site, Georgia Office of Commissioner of Insurance and Safety Fire
Not confirmed (9)
  • The deadline to request independent review. no filing deadline for the state independent review appears in the rules loaded; the state statute itself (O.C.G.A. 33-20A-30 and following) was not loaded
  • The independent review request form. the rules say the plan must send the state's request forms with its final decision; no form was found online
  • How to file for independent review. the mailing address comes from the Department of Community Health page announcing the 2022 transfer; the insurance commissioner's own site has no consumer page on independent review
  • Which denials qualify for independent review. which plans count as 'managed care plans' under the state law was only summarized from the rules; the Centers for Medicare & Medicaid Services lists Georgia as a federal-process state
  • A searchable list of past decisions. none found
  • Published results of independent review. none found
  • Free consumer help programs. the Centers for Medicare & Medicaid Services lists no Consumer Assistance Program for Georgia and names the insurance commissioner's office (800-656-2298) as the resource; no statewide legal-aid program was verified
  • The Medicaid fair hearing deadline. the 120-day managed care deadline and the 10-day rule to keep benefits come from health plan materials, not a Department of Community Health page
  • Not confirmed. stateLaws[1].url and stateLaws[2].url — statute text read on georgiacommons.org, a non-government copy of the Georgia Code

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