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

25 HB 197/AP House Bill 197 (AS PASSED HOUSE AND SENATE) By: Representatives Hawkins of the 27th, Newton of the 127th, Kelley of the 16th, Silcox of the 53rd, Cooper of the 45th, and others A BILL TO BE ENTITLED AN ACT To amend Code Section 33-46-6 of the Official Code of Georgia A nnotated, relating to1 requirements for certification, utilization of nationally recog nized accreditation standards,2 and website identifying nationally recognized accreditation entities, so as to detail the effort3 that shall be made by treating health care provider to respond to a private review agent or4 utility review entity's attempt to reach such provider to discuss the patient's care; to amend5 Chapter 46 of Title 33 of the Official Code of Georgia Annotated, relating to certification of6 private review agents, so as to provide for health insurers to implement and maintain a7 program that allows for the selective application of reductions in prior authorization8 requirements under certain circumstances; to provide for an annual filing; to provide for the9 promulgation of rules and regulations; to provide for related m atters; to provide for an10 effective date and applicability; to repeal conflicting laws; and for other purposes.11 BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:12 SECTION 1.13 Code Section 33-46-6 of the Official Code of Georgia Annotated, relating to requirements14 for certification, utilization of nationally recognized accredi tation standards, and website15 H. B. 197 - 1 - 25 HB 197/AP identifying nationally recognized accreditation entities, is amended by revising paragraph (5)16 of subsection (a) as follows:17 "(5) In any instances where the private review agent or utiliza tion review entity is18 questioning the medical necessity of care, the treating health care provider, or such19 provider's appropriately qualified designee, shall be able to discuss the plan of treatment20 with a clinical peer trained in a related specialty and no adverse determination shall be21 made by the private review agent or utilization review entity u ntil an effort has been22 made to discuss the patient's care with the patient's treating provider, or such provider's23 appropriately qualified designee who shall be familiar with the patient's case, during24 normal working hours. Such effort shall include contacting the treating provider or his25 or her designee, implementing a callback telecommunications sys tem, or the use of a26 public website whereby such provider or designee may elect to r eceive a scheduled27 communication at a later time in the event that a clinical peer is not available. In the28 event of an adverse determination, notice to the provider will specify the reasons for the29 review determination;"30 SECTION 2.31 Chapter 46 of Title 33 of the Official Code of Georgia Annotated, relating to certification of32 private review agents, is amended by adding a new Code section to read as follows:33 "33-46-20.1.34 (a) Each insurer that utilizes prior authorization requirement s shall implement and35 maintain a program that allows for the selective application of reductions in prior36 authorization requirements based on the stratification of healthcare providers' performance37 and adherence to evidence based medicine. Such program shall p romote quality,38 affordable healthcare and reduce unnecessary administrative burdens for both the insurer39 and the healthcare provider.40 H. B. 197 - 2 - 25 HB 197/AP (b) Criteria for participation by healthcare providers and the healthcare services included41 in the program shall be at the discretion of the insurer; provided, however, that such insurer42 shall submit to the department a filing concerning such program. Such filing shall include43 a full narrative description of the program, the criteria for participation in the program, a44 list of the procedures and services subject to the program, the number of healthcare45 providers participating in the program, and any other information deemed necessary by the46 department.47 (c) No later than July 1, 2026, each insurer that utilizes prior authorization requirements48 shall make the filing provided fo r in subsection (b) of this Co de section, and such filing49 shall be submitted annually in a form and manner provided for b y rules and regulations50 promulgated by the Commissioner."51 SECTION 3.52 This Act shall become effective on January 1, 2026, and shall a pply to all policies or53 contracts issued, delivered, issued for delivery, or renewed in this state on or after such date.54 SECTION 4.55 All laws and parts of laws in conflict with this Act are repealed.56 H. B. 197 - 3 -