Utilization Review Agents/Private Review Agents

 

Initial Certifications and Re-certifications (renewals)

As of July 1, 2025, all filings are to be completed in Sircon.com. Below is the information for type of filing, instructions and links to resources, documents and systems. Emailed documents for certifications and recertifications will not be accepted unless specifically requested by OCI. 

  • For initial certifications, we will review within 10 days of receipt and will send an approval email notice or a deficiency notice to provide any required items.
  • For recertifications, we will review within 10 days of receipt and will send an approval email notice or a deficiency notice to provide any required items.

Recertification reminder: Approximately 90 days before the expiration date of the certification, an email will be sent from Sircon.com as a reminder to file for recertification.

For all deficient notices, the applications and renewals will be closed out incomplete if deficient items are not provided within 60 days of the deficiency notice. Applicants will then need to reapply. 

APPLYING FOR PRIVATE REVIEW AGENT CERTIFICATION

  • Gather Information and Documents
    • Organizational Documents - Articles of Incorporation, partnership agreement and all amendments and any other documents showing trade name certificates, trust agreements. If private review agent utilizes a fictitious or dba, attach a copy of any recorded approvals.
    • Copy of By-laws, or similar documents regulating the affairs of the private review agent with attestation of officers or principal partners
    • List names, addresses and official titles of positions held by individuals who are responsible for the conduct of the affairs of the entity
    • Biographical Affidavit (link below to form) for each person listed
    • Be prepared to enter the SSNs for all Officers or Owners during the electronic application process
    • Prepare to provide mailing and business addresses of organization
    • Prepare to provide name of attorney or principal filing application along with the mailing address
    • Utilization Review Plan
    • URAC and/or NCQA Certifications or statements of status of applying or if not applicable
    • List of type, qualifications and number of personnel, either employed or under contract, to perform utilization reviews
    • Copy of materials and notices designed to inform patients and health care providers of requirements of the utilization review plan
    • Quality Assessment Program documentation
    • Written policy and procedure documentation ensuring representatives are available to patients and providers for at least five (5) days a week during normal business hours
    • Written policy and procedures documentation ensuring compliance with all state laws and regulations to protect confidentiality of information obtained in the course of utilization reviews
    • Written policy and procedures for establishing and maintaining a complaint system
    • Copies of any contracts or agreements to be executed between the private review agent and payor, employer, claim administrator, or other entity with certification that no incentive payment provision exist for the private review agent based on reduction of services or other charges thereof, reduction of length of stay, or utilization of alternative treatment settings to reduce the amounts of necessary or appropriate medical care
    • Advertising materials used in the State of Georgia
    • Citizenship Affidavit and copy of the front of an acceptable ID (link to form below)
    • Payment of $1,000 plus $5 processing fee and any system fees
  • Access application in Sircon.com
    1. Access www.Sircon.com/Georgia
    2. Under Licensees, select Apply for a License
    3. At the next screen,
      1. Select New Insurance License
      2. Click on radio button for Resident or Non-resident (if business is located in Georgia, select Resident; if business is located outside of Georgia, select Non-resident)
      3. and then click on radio button for Firm
    4. At next screen,
      1. Enter Legal Name of Entity
      2. Enter EIN
      3. Select Applicant if you are employed by the entity or Authorized Submitter if you are a contracted entity assisting in the certification process
      4. Select Georgia
    5. Enter the Payment Method which will be used at the end of the application process
    6. At the next screen, select Private Review Agent and continue
    7. At the Agency Information screen,
      1. The FEIN and Name previously entered will populate
      2. Enter Incorporation Date
      3. Enter Type of entity - Limited Liability Company, Incorporation, etc.
      4. Domicile Country
      5. If Affiliated with a Bank - Yes or No
      6. Email address - this will be the email used for system notifications
      7. Business website if available
      8. FINRA CRD Identifier not applicable to this license type
    8. At next screen,
      1. Enter the business address (physical location - no PO Boxes are acceptable) and the mailing address. If both are the same, you can use the Copy From for your convenience
      2. Enter Business Phone Number and Fax (if fax not used, enter the business phone number for both)
    9. At next screen, Enter the Owners or Officers of the entity. You will be required to enter the SSNs for each individual and the percentage of ownership, if applicable
    10. At next screen, you will begin answering the application questions. These will cover the items listed above in the "Gather Information and Documents"
    11. The Attestation screen will appear. Please read and agree if you wish to submit the application.
    12. The License Application Summary screen will appear showing the details. You can click on the "Review License Application" in red to read through our submittal. You can also at the lower part of the screen, click to review the list of requirements.
    13. Click on Submit
    14. The License Application Confirmation page will appear.
      1. You can print the confirmation page for your records.
      2. You can also click on the Confirmation ID for a printable version of your application submission. 

     

  • What to Expect after Filing
    • Sircon.com system will send an email acknowledging the filing of the application
    • An OCI analyst will review the submittal within ten (10) days
    • A deficiency email will be sent if any requirements have not been completed
    • When approved, an email will be sent from the Sircon.com system with the certification document
    • If the application is not completed within 60 days of the deficiency notices, the application could be closed incomplete and the entity will need to reapply. 

     

     

APPLYING FOR PRIVATE REVIEW AGENT RECERTIFICATION

  • Gather Information and Documents
    1. For the following requirements if there are no material changes, you can provide a statement on company or representing attorney letterhead, attesting to that fact. All can be included in one statement.
      1. Organization Documents
      2. By-laws or other similar documents
      3. Utilization Review Plan
      4. Materials Used to Inform patients and health care providers of utilization review plan
      5. Materials Used to Inform patients and health care providers of Utilization Review requirements
      6. Quality Assessment Program
      7. Written Policy and Procedures of PRA Accessibility to patients and providers
      8. Written Policy and Procedures of Confidentiality of Information
      9. Written Policy and Procedures for Complaint System
      10. Advertising Materials used in State of Georgia
      11. Agreements or contracts used between PRA and payor, employer, claim administrator, or other entity, regarding incentive payment provisions
    2. URAC and/or NCQA Certifications or statement if not applicable
    3. List of type, qualifications and number of personnel, either employed or under contract, that perform utilization reviews
    4. Biographical Affidavits for any new responsible individuals
    5. Citizenship Affidavit and ID if the original submitter is no longer with the entity
    6. Payment of $500 renewal fee, plus $5 processing fee and any system fees
  • Submit Recertification
    1. Access www.Sircon.com/Georgia
    2. Under Licensees, select Renew or Reinstate a License
    3. At the next screen,
      1. Select Renew Insurance License
      2. Select radio button for Firm
    4. At next screen,
      1. Select Georgia as renewal state
      2. Enter EIN
      3. Select Georgia as the Resident State
      4. Enter Georgia License Number (new assigned number not the PRA number)
      5. If your renewal is not found, click on Search for a specific license under the Cancel box
        1. Enter EIN
        2. Enter Georgia License number (not the PRA number)
        3. click Continue
      6. When renewal is found, select Renew under Action and Continue
    5. Enter the Payment Method which will be used at the end of the application process
    6. At the next screen, select Private Review Agent and continue
    7. Review Business and Mailing Addresses and make any needed updates
    8. At next screen, you will begin answering the application questions. These will cover the items listed above in the "Gather Information and Documents"
    9. The Attestation screen will appear. Please read and agree if you wish to submit the application.
    10. The License Fee Summary screen will appear to review. Select Review to Review responses, Process to file the renewal or Cancel to end the submittal. 
  • What to Expect after Filing
    • Sircon.com system will send an email acknowledging the filing of the application
    • An OCI analyst will review the submittal within ten (10) days
    • A deficiency email will be sent if any requirements have not been completed
    • When approved, an email will be sent from the Sircon.com system with the recertification document
    • If the renewal is not completed by the expiration date, the renewal could be closed incomplete and the entity will need to reapply. 

UPDATES AND CHANGES

Updates and changes to the organization between renewals can be emailed to [email protected]. We will acknowledge receipt via return email within three (3) business days. Please provide the Georgia license number on all communications.

If you are requesting a surrender of your Georgia certification, please provide 60 days notice via email to [email protected]. We will acknowledge receipt and provide information for process. 

ANNUAL REPORT FILING

Annual Reports are to be filed by March 1 of each year and can be emailed to [email protected]. Please do not send under a private, encrypted or restricted mode. We will not be able to open those type of emails. When received, you will receive an acknowledgement within two business days. Link to form below.

Questions and request for assistance can be sent to [email protected]. A response should be received within one business day.

FORMS:

Contact

Sircon Website to Apply, Renew and Update Licenses

Sircon.com/Georgia

RESOURCES: