Georgia's two systems: the federal appeal, and the state program beside it

Open now, and a deadline extension runs to October 2, 2026

The federal process was unavailable for part of this summer. CMS closed the HHS-administered Federal External Review Process between July 1 and August 3, 2026 and reopened it on July 31, 2026, and it has extended the filing deadline for people the closure shut out.

• If you could not request external review between July 1, 2026 and August 3, 2026, you may be eligible — and if you are, you have until October 2, 2026 to request it.
• The extension also reaches any state: it covers a self-insured non-Federal governmental health plan that uses the federal process, wherever the plan is.
• If you submitted a request before July 1, 2026, you do not need to resubmit or send anything further now.
• If you already received a final decision through the federal process, the extension does not apply to you.

No adverse determination before the conversation

Georgia puts a precondition on the denial itself. No adverse determination may be made until an effort has been made to discuss the patient's care, during normal working hours, with the treating provider or a qualified designee familiar with the case — and the treating provider must be able to discuss the plan of treatment with a clinical peer trained in a related specialty.

A clinical peer here is licensed without restriction, currently in active practice in the same or a similar specialty as the treating provider, typically manages the condition at issue, and has knowledge and experience of the service under review.

Two tracks, and the denial notice names yours

CMS's external-appeals table, updated 07/09/2024, places Georgia in the HHS Administered Process / Independent Review Organization Process column — the state's own program is not treated as meeting the federal minimum standards. A non-grandfathered insured plan in Georgia therefore lands on one of two ACA routes: the HHS-administered Federal External Review Process, operated under contract by MAXIMUS Federal Services, or an accredited independent review organization the issuer has contracted with under 45 CFR 147.136(d). The plan's denial notice has to identify which process applies.

Georgia's own Patient's Right to Independent Review program did not disappear when that happened. It still runs under O.C.G.A. § 33-20A-30 and following, with rules at Ga. Comp. R. & Regs. 120-2-111, for managed care plans — major medical, hospitalization, and stand-alone dental. That program is live; it simply is not the ACA external-review vehicle, and the two differ on filing address, clock, and who chooses the reviewer.

• ACA route, HHS-run: the request goes to MAXIMUS — not to the carrier, and not to a Georgia agency.
• ACA route, issuer-contracted: the request goes to the plan, which must refer it out to one of the accredited IROs it holds contracts with.
• Georgia's state review: the request goes to the insurance regulator, and under Rule 120-2-111-.04(4)(b) only the enrollee or a person acting on the enrollee's behalf may make it.

Four months — and the 2026 extension that may have revived a stale case

The federal window is four months after receipt of the adverse benefit determination or the final internal adverse determination. CMS states it in calendar months rather than days, so count it on a calendar; converting it to 120 days is a guess that can cost a case at the margin. The same four-month floor applies on the issuer-contracted route under 45 CFR 147.136.

One 2026 wrinkle is worth checking before writing off any Georgia denial. The HHS-administered process was unavailable for part of 2026 and reopened 07/31/2026. CMS extended the filing deadline for consumers in Georgia — along with Alabama, Florida, Texas, Wisconsin, and several territories — whose four months expired between 07/01/2026 and 08/03/2026: those requests may still be filed with MAXIMUS through 10/02/2026.

Georgia's own act is unusual on the patient's clock. Neither O.C.G.A. §§ 33-20A-32 through 33-20A-36 nor Rules 120-2-111-.04 and .05 states any number of days for an enrollee to bring a request to the Department. The 60- and 30-day figures that do appear in Rule 120-2-111-.04(3) are deadlines on the carrier to finish its grievance, not on the patient to file. A 60-day patient deadline circulates on consumer sites for Georgia; it does not trace to the statute, the rules, or an OCI page, so don't calendar against it — file from the denial notice, early.

How to file, by track

1. 1

   Read the denial notice for the route

   It must identify the external-review process that applies. HHS-run means the request goes to MAXIMUS; issuer-contracted means it goes back to the plan, which then refers it out.

2. 2

   Federal track: file with MAXIMUS

   The FERP portal at externalappeal.cms.gov/ferpportal is the channel CMS says it prefers; mail, fax, and email are also accepted. Nothing is sent to the carrier or to a Georgia agency on this track.

3. 3

   State track: write to the regulator, not the insurer

   Mail the request to the Office of Commissioner of Insurance and Safety Fire, Attn: Administrative Procedure Department, 2 Martin Luther King Jr. Drive, West Tower Suite 704, Atlanta, GA 30334.

4. 4

   Send what the rule actually asks for

   Rule 120-2-111-.05(2) requires no particular format: a written request naming the enrollee, the address, the representative if there is one, plus a copy of the carrier's adverse grievance-outcome notice, is sufficient. The carrier must enclose the Department's forms with that notice; forms questions go to [email protected].

5. 5

   File as the patient's representative

   Georgia's state review may be requested only by the enrollee or someone acting on the enrollee's behalf, so a practice files in that capacity — on the patient's clock, with the patient's authorization in the packet.

Who picks the reviewer: three answers, and one of them is the carrier

This is the single most useful thing to know about Georgia. The track a denial is on decides who selects the independent reviewer, and the three answers are not equivalent.

• Georgia's state process — the regulator assigns. Rule 120-2-111-.05(3) gives the Department three working days from receipt to acknowledge and assign, rotating by date received. Rule 120-2-111-.14 adds that IROs enter the list in order of certification date, assignment runs chronologically down that list to the first organization with no apparent conflict, and an IRO skipped for conflict keeps its position rather than dropping to the bottom. The carrier has no say.
• HHS-administered federal process — HHS assigns, through its contractor MAXIMUS.
• Issuer-contracted federal route — the plan or issuer assigns. 45 CFR 147.136(d)(1)(iii)(A) constrains it (at least three accredited IROs under contract, rotating assignment or another unbiased method such as random selection, no financial incentive tied to upholding denials), but the party choosing is the carrier.

The clocks, and who pays

• Federal, standard: decided as expeditiously as possible and no later than 45 days after the examiner receives the request; the issuer must hand over its file within five business days.
• Federal, expedited: 72 hours from receipt. The decision may be given orally, with written confirmation within 48 hours.
• A MAXIMUS decision is final and binding on the plan, with no further administrative appeal.
• Georgia state process: the carrier delivers its file to the assigned IRO within three working days of the assignment notice; the reviewer has five working days to request anything further; parties have five working days to respond; extensions cap at ten working days; the decision follows within 15 working days after those deadlines run — in writing, with findings of fact and the documents relied on, by certified mail to the carrier, the enrollee, and the Department.
• Georgia expedited: 72 hours from the reviewer receiving all requested documentation, available where the treating provider judges that ordinary timing would jeopardize life, health, or the ability to regain maximum function.
• Cost to the patient or the practice on either track: nothing. FERP is free to the plan, the consumer, and the consumer's authorized representative.
• On the state track the managed care entity pays the entire cost (O.C.G.A. § 33-20A-34). Rule 120-2-111-.13 fixes it at $1,500 for a tier-one review — one conducted by an MD or DO — and $1,000 for any other type, plus copying, fax, postage, and courier. The IRO bills the carrier, which must pay within 30 days; late payment carries the penalty in O.C.G.A. § 33-20A-35.

What Georgia's own rules say about why the tracks split

Georgia's independent review carries a dollar floor. O.C.G.A. § 33-20A-33 and Rule 120-2-111-.04(4)(a) require the proposed treatment to involve at least $500 of expenditure before review is available. Federal rule speaks to exactly that: 45 CFR 147.136(c)(2)(v) tells states a compliant process may not impose a restriction on the minimum dollar amount of a claim, and uses a $500 threshold as its example. The same subsection requires a filing window of at least four months, which Georgia's act does not set, and requires that the reviewer in no event be selected by the issuer. CMS publishes no per-state rationale, so read the connection as an inference from the two texts rather than a CMS finding.

Two more details a Georgia packet should get right. The program changed hands: HB 1013, signed 04/04/2022, moved the Patient's Right to Independent Review Act from the Department of Community Health to the insurance commissioner effective 07/01/2022. Filing instructions pointing at DCH — still circulating in payer letters and older guides — send the request to the wrong agency. And under Rule 120-2-111-.03(15)(d) the burden of proof in the state review sits on the managed care entity, which is not how the carrier frames its own internal appeal.

At a rulemaking hearing on 06/04/2025, the Commissioner proposed amendments to Subject 120-2-111 that would deem nationally accredited IROs certified without a separate Georgia application and allow the Department to reject a duplicate independent-review request already assigned — a real limit on a second attempt at the same denial. The hearing notice and the redline are confirmed; whether the amendments were adopted, and when they took effect, is not. Treat it as pending and check before relying on either point.

• Stand-alone dental is explicitly in scope, and a dental case must be reviewed by a licensed dentist.
• $500 minimum expenditure to qualify for the state review (O.C.G.A. § 33-20A-33; Rule 120-2-111-.04(4)(a)).
• IRO certification runs through the Department: $500 to certify, $250 a year to renew.

For Georgia providers and billers: the automatic-authorization rule

Georgia's prior-authorization statute is enforceable in an unusually direct way. SB 80 (2021), the Ensuring Transparency in Prior Authorization Act, rewrote O.C.G.A. Chapter 33-46 effective 01/01/2022, and § 33-46-29 provides that a violation of any deadline or other requirement of the chapter results in automatic authorization of the service under review. Each obligation below is worth date-stamping in the file and citing by section when a payer misses it.

• Response within 15 calendar days after all necessary information is received, tightened to 7 calendar days from 01/01/2023 (§ 33-46-26); 72 hours for urgent services (§ 33-46-27).
• No prior authorization for emergency, urgent, or incidental services, or for emergency ambulance (§§ 33-46-24, -25).
• An appeal must be reviewed by a like-specialty clinician who was not involved in the original denial (§ 33-46-22).
• A granted authorization cannot be revoked if services begin within 45 business days (§ 33-46-23), and an existing authorization carries 30 days of continuity across a coverage switch (§ 33-46-28).
• Insurers must publish current PA requirements on a provider-accessible website, update it before any new or amended requirement takes effect, and publish per-plan statistics on approvals, denials, denial reasons, appeals, outcomes, and turnaround time (§ 33-46-20).
• Step therapy runs on a separate exception process at O.C.G.A. § 33-24-59.25, under which carrier silence results in deemed approval. The response timeframes circulating for it could not be confirmed against the official text, so verify the count before relying on a specific number.