Section 33-20A-31 - DefinitionsAs used in this article, the term:
(1) "Addictive disease" has the same meaning as in Code Section 37-1-1.(1.1) "Department" means the Department of Insurance.(2) "Eligible enrollee" means a person who: (A) Is an enrollee or an eligible dependent of an enrollee of a managed care plan or was an enrollee or an eligible dependent of an enrollee of such plan at the time of the request for treatment;(B) Seeks a treatment which reasonably appears to be a covered service or benefit under the enrollee's evidence of coverage; provided, however, that this subparagraph shall not apply if the notice from a managed care plan of the outcome of the grievance procedure was that a treatment is experimental; and(C) Is not a Medicaid care management member.(2.1) "Generally accepted standards of mental health or substance use disorder care" means evidence based independent standards of care and clinical practice that are generally recognized by health care providers practicing in relevant clinical specialties such as psychiatry, psychology, clinical sociology, addiction medicine and counseling, and behavioral health treatment. Valid, evidence based sources reflecting generally accepted standards of mental health or substance use disorder care may include peer reviewed scientific studies and medical literature, consensus guidelines and recommendations of nonprofit health care provider professional associations and specialty societies, and nationally recognized clinical practice guidelines, including, but not limited to, patient placement criteria and clinical practice guidelines; guidelines or recommendations of federal government agencies; and drug labeling approved by the United States Food and Drug Administration.(3) "Grievance procedure" means the grievance procedure established pursuant to Code Section 33-20A-5.(4) "Independent review organization" means any organization certified as such by the department under Code Section 33-20A-39.(5) "Medicaid care management member" means a recipient of medical assistance, as that term is defined in paragraph (7) of Code Section 49-4-141, and shall also include a child receiving health care benefits pursuant to Article 13 of Chapter 5 of Title 49.(6) "Medical and scientific evidence" means:(A) Peer reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff;(B) Peer reviewed literature, biomedical compendia, and other medical literature that meet the criteria of the National Institutes of Health's National Library of Medicine for indexing in Index Medicus, Excerpta Medicus (EMBASE), Medline, and MEDLARS data base or Health Services Technology Assessment Research (HSTAR);(C) Medical journals recognized by the United States secretary of health and human services, under Section 1861(t)(2) of the Social Security Act;(D) The following standard reference compendia: the American Hospital Formulary Service-Drug Information, the American Medical Association Drug Evaluation, the American Dental Association Accepted Dental Therapeutics, and the United States Pharmacopoeia-Drug Information; or(E) Findings, studies, or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes including the Federal Agency for Health Care Policy and Research, National Institutes of Health, National Cancer Institute, National Academy of Sciences, the Centers for Medicare and Medicaid Services, and any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health services.(7) "Medical necessity," "medically necessary care," or "medically necessary and appropriate" means: (A) Except as otherwise provided in subparagraph (B) of this paragraph, care based upon generally accepted medical practices in light of conditions at the time of treatment which is: (i) Appropriate and consistent with the diagnosis and the omission of which could adversely affect or fail to improve the eligible enrollee's condition;(ii) Compatible with the standards of acceptable medical practice in the United States;(iii) Provided in a safe and appropriate setting given the nature of the diagnosis and the severity of the symptoms;(iv) Not provided solely for the convenience of the eligible enrollee or the convenience of the health care provider or hospital; and(v) Not primarily custodial care, unless custodial care is a covered service or benefit under the eligible enrollee's evidence of coverage; or(B) With respect to the treatment of a mental health or substance use disorder, a service or product addressing the specific needs of that patient for the purpose of screening, preventing, diagnosing, managing or treating an illness, injury, condition, or its symptoms, including minimizing the progression of an illness, injury, condition, or its symptoms, in a manner that is: (i) In accordance with the generally accepted standards of mental health or substance use disorder care;(ii) Clinically appropriate in terms of type, frequency, extent, site, and duration; and(iii) Not primarily for the economic benefit of the insurer, purchaser, or for the convenience of the patient, treating physician, or other health care provider.(7.1) "Mental health or substance use disorder" means a mental illness or addictive disease.(7.2) "Mental illness" has the same meaning as in Code Section 37-1-1.(8) "Treatment" means a medical or mental health or substance use disorder service, diagnosis, procedure, therapy, drug, or device.(9) Any term defined in Code Section 33-20A-3 shall have the meaning provided for that term in Code Section 33-20A-3 except that "enrollee" shall include the enrollee's eligible dependents.Amended by 2022 Ga. Laws 587,§ 1-3, eff. 7/1/2022.Amended by 2009 Ga. Laws 102,§ 1-7, eff. 7/1/2009.Amended by 2006 Ga. Laws 453,§ 33, eff. 4/14/2006.Added by 2005 Ga. Laws 399,§ 2, eff. 5/10/2005.Amended by 2002 Ga. Laws 462, § 33, eff. 4/18/2002.