Governance

Private Review Agent

An entity certified to conduct utilization review for healthcare services coverage.

Definitions (2)

Private review agents are entities, as defined in Chapter 46 of Title 33 of the Official Code of Georgia Annotated, responsible for assessing the medical necessity and appropriateness of healthcare services for insurance purposes. They conduct utilization reviews to determine coverage.

AN ACT To amend Chapter 46 of Title 33 of the Official Code of Georgia Annotated, relating to certification of private review agents, so as to provide that certain decisions with regard to the provision of insurance coverage for healthcare services shall not be based solely on artificial intelligence systems, artificial intelligence, or other software tools; to provide for definitions; to provide for related matters; to provide for an effective date; to repeal conflicting laws; and for other purposes.Definition 1 of 2

An entity that performs utilization review for a carrier or PBM.

Health Insurance – Utilization Review – Use of Artificial IntelligenceDefinition 2 of 2
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