New to helping someone in Georgia?
Start with three things from the patient or family:
- Insurance card — shows the carrier and plan name
- Denial letter or explanation of benefits (EOB) — lists appeal rights and deadlines
- Summary of Benefits and Coverage (SBC) — if available
Your first job is to learn what kind of plan this is (Georgia Access, job-based, Medicaid, Medicare) and what deadline the letter gives you.
For steps that work in every state, use these general guides first, then return here for Georgia rules:
What is different in Georgia?
- Georgia Access: Georgia runs its own Marketplace at georgiaaccess.gov (major issuers include Anthem BCBS GA, Kaiser, Ambetter, and others).
- Prior authorization transparency (2021+): Non-urgent PA within 7 calendar days after the insurer has all needed information; urgent within 72 hours; clinical criteria must be disclosed (O.C.G.A. §§ 33-46-26, 33-46-27).
- State external review: Submit to the Georgia Office of Commissioner of Insurance (OCI) after internal appeal—often 30 days standard, 72 hours expedited (O.C.G.A. § 33-20A-35).
- Managed care independent review:HMO and managed care enrollees may also use the Patient's Right to Independent Review Act (O.C.G.A. Ch. 33-20A).
- Georgia Medicaid (Care Management Organizations): MCO appeal, then DCH fair hearing.
Who is in charge of your plan?
- Georgia Office of Commissioner of Insurance (OCI): Fully insured health plans, external review, complaints — oci.georgia.gov. Consumer line: 800-656-2298 (outside Atlanta) or 404-656-2070.
- U.S. Department of Labor: Many self-funded employer plans.
- Georgia DCH: Medicaid fair hearings — dch.georgia.gov.
- CMS: Medicare and Medicare Advantage.
For complaints after appeals, see Regulator complaints.