HB 1236: Insurance; medical necessity of a healthcare service; provisions

Under current Georgia law (O.C.G.A. § 33-46-6), when a private review agent or utilization review entity for a health insurance plan questions whether a healthcare service is medically necessary, the treating provider can discuss the case with a clinical peer, but that peer does not have to be licensed in Georgia and does not have to formally agree before the insurer denies coverage. This bill changes that. It requires the reviewing clinical peer to be licensed in Georgia, and it says no adverse determination (a denial of coverage) can be made unless that licensed clinical peer agrees with it, in addition to the existing requirement that an effort be made to discuss the case with the treating provider. It also requires that when a denial is issued, the notice sent to the treating provider must state the reasons for the decision. The change would take effect January 1, 2027, and apply to insurance policies issued, delivered, or renewed in Georgia on or after that date.

• Requires that the clinical peer reviewing a medical necessity dispute be licensed in the state of Georgia, not just trained in a related specialty.
• Bars an insurer's private review agent or utilization review entity from issuing an adverse coverage determination unless the licensed clinical peer agrees with it.
• Changes the notice requirement so that when coverage is denied, the insurer 'must' (rather than 'will') specify the reasons for the determination to the treating provider.
• Sets an effective date of January 1, 2027, applying to insurance policies or contracts issued, delivered, or renewed in Georgia on or after that date.

Health insurance companies and their utilization review entities or private review agents, treating healthcare providers who submit care plans for review, and patients in Georgia whose insurance coverage depends on a medical necessity determination.

Patients could see fewer coverage denials issued without a Georgia-licensed clinical peer's agreement, and providers would get a clearer, mandatory explanation when a service is denied. This changes the internal review process insurers already use for medical necessity disputes.

• Section 1 amends paragraph (5) of subsection (a) of O.C.G.A. § 33-46-6 to require the clinical peer be 'licensed in this state' in addition to being trained in a related specialty.
• Section 1 adds that no adverse determination may be made 'unless such determination is agreed to by such licensed clinical peer,' beyond the existing requirement to attempt discussion with the treating provider.
• Section 1 changes notice language from 'will' to 'must' specify reasons for an adverse review determination.
• Section 2 sets the effective date as January 1, 2027, applying to policies or contracts issued, delivered, or renewed on or after that date.
• Section 3 repeals conflicting laws.

1. 2026-02-24House Committee Favorably Reported (House)
2. 2026-02-10House Second Readers (House)
3. 2026-02-09House First Readers (House)
4. 2026-02-06House Hopper (House)

• Trey Kelley (R, HD-016)Primary sponsor
• Mark Newton (R, HD-127)
• James Hatchett (R, HD-155)
• Karen Mathiak (R, HD-082)
• Demetrius Douglas (D, HD-078)
• Patty Stinson (D, HD-150)

• health insurance
• medical necessity reviews
• utilization review
• patient protections
• insurance regulation