HB197: HB197 Insurance; health care provider to respond to a private review agent or utility review entity's attempt to discuss the patient's care; detail the effort

Under current Georgia law, before an insurer's private review agent can deny coverage for medical necessity reasons, some effort must be made to discuss the case with the treating provider. This bill spells out exactly what that effort must look like: contacting the provider directly, using a callback phone system, or offering a public website where the provider can schedule a later call if a clinical peer isn't immediately available. The bill also creates a new requirement for insurers that use prior authorization (the practice of requiring advance approval before covering certain care). Insurers must set up programs that reduce prior authorization requirements for providers who show strong performance and follow evidence based medicine. Insurers must file details of these programs annually with the Georgia Department of Insurance, starting no later than July 1, 2026. The law takes effect January 1, 2026, and applies to policies issued or renewed on or after that date.

• Requires review agents to make specific documented efforts (direct contact, callback system, or scheduling website) to reach a treating provider before denying coverage for medical necessity.
• Requires insurers using prior authorization to create programs that reduce those requirements for providers who perform well and follow evidence based medicine.
• Requires insurers to file a detailed annual description of these reduction programs with the Georgia Department of Insurance, including participation criteria and provider counts.
• Sets July 1, 2026 as the deadline for the first annual filing and directs the Insurance Commissioner to create rules governing the filing process.
• Sets the law's effective date as January 1, 2026, applying to insurance policies and contracts issued or renewed on or after that date.

Health insurers and their private review agents or utilization review entities, treating health care providers such as doctors and their designees, patients whose care is subject to prior authorization or medical necessity review, and the Georgia Department of Insurance, which oversees the new filings.

Patients facing insurance denials would benefit from clearer rules requiring insurers to actually try reaching their doctor before an adverse decision. Providers with strong track records could face fewer prior authorization hurdles, potentially speeding up patient care and reducing paperwork for both providers and insurers.

• Section 1 revises O.C.G.A. § 33-46-6(a)(5) to require that review agents' effort to reach a treating provider include direct contact, a callback telecommunications system, or a scheduling website option.
• Section 1 requires that any adverse determination notice specify the reasons for the review decision.
• Section 2 adds new O.C.G.A. § 33-46-20.1, requiring insurers using prior authorization to implement programs reducing those requirements based on provider performance and evidence based medicine.
• Section 2 requires insurers to file a narrative description of the program, participation criteria, covered procedures, and participating provider counts with the Department of Insurance.
• Section 2 sets July 1, 2026 as the deadline for the first annual filing, with future filings governed by Commissioner rules.
• Section 3 sets the effective date as January 1, 2026, applying to policies issued, delivered, or renewed on or after that date.

1. 2025-05-14Effective Date 2026-01-01
2. 2025-05-14Act 303
3. 2025-05-14House Date Signed by Governor (House)
4. 2025-04-09House Sent to Governor (House)
5. 2025-04-04House Agreed Senate Amend or Sub (House)
6. 2025-04-02Senate Passed/Adopted By Substitute (Senate)
7. 2025-04-02Senate Third Read (Senate)
8. 2025-04-02Senate Taken from Table (Senate)

• Lee Hawkins (R, HD-027)Primary sponsor
• Mark Newton (R, HD-127)
• Trey Kelley (R, HD-016)
• Deborah Silcox (R, HD-053)
• Sharon Cooper (R, HD-045)
• Michelle Au (D, HD-050)
• Kay Kirkpatrick (R, SD-032)

1. PassedHouse voteMarch 4, 2025

   174 yea, 0 nay (4 not voting, 2 absent)

   Passage: House Vote #153

2. PassedSenate voteApril 2, 2025

   53 yea, 0 nay (1 not voting, 2 absent)

   Passage By Substitute: Senate Vote #433

3. PassedHouse voteApril 4, 2025

   162 yea, 0 nay (6 not voting, 12 absent)

   Agree To Senate Substitute: House Vote #413

• health insurance
• prior authorization
• medical necessity reviews
• insurance regulation
• patient care