Georgia CommonsHouse · Introduced · 2025-2026 Regular Session
HB 1236: Insurance; medical necessity of a healthcare service; provisions
Last action February 24, 2026 · House Committee Favorably Reported
A Georgia House bill would require that insurance denials based on medical necessity get sign-off from a clinical peer licensed in Georgia before a treating provider's care can be overruled.
The summaries below were written by an AI model (claude-sonnet-5) from the text of the bill and are not part of it. Quote the text, not the summary. The stored text is the Introduced version, the latest the General Assembly's website lists.
In plain language
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.
What the bill does
- 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.
Who it affects
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.
Why it matters
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.
Key provisions
- 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.
Discussed in meetings (5)
The House and Senate meetings that took this bill up, from their machine transcripts. Each account was written by Georgia Commons with AI and is not part of the record; the video is what was said.
House Health Committee, February 23, 2026
From 1:22:43 · Watch on the General Assembly's Vimeo channel
Summary by Georgia Commons: The sponsor said HB 1236 would require a Georgia-licensed medical professional to review a health plan's decision that recommended treatment is not medically necessary. The sponsor said denying care amounts to practicing medicine and argued that Georgia licensing would provide accountability. Members asked whether physician shortages could delay reviews or raise insurance costs, whether reviewers must have similar expertise, and how patients would learn the reasons for denial. The sponsor said plans could contract with licensed professionals, the clinical-peer language addresses expertise, and treating providers generally relay denials to patients. Another member questioned the breadth of existing language about questioning medical necessity. The sponsor said the requirement would apply before an adverse decision, not necessarily to every earlier review. A Georgia Association of Health Plans witness opposed the bill, warning of higher costs, delays and reduced access to specialists. The witness said almost all prior authorizations are approved and two smaller member plans already use Georgia-licensed reviewers. The committee approved the bill by voice vote.
House Rules Committee, February 25, 2026
From 1:28:24 · Watch on the General Assembly's Vimeo channel
Summary by Georgia Commons: The presenter said HB 1236 would require a health plan's decision to deny recommended medical care to be made by a medical provider licensed in Georgia. No questions or scheduling decision followed.
Status timeline
- House Committee Favorably Reported (House)
- House Second Readers (House)
- House First Readers (House)
- House Hopper (House)
Sponsors
- Trey Kelley (R, HD-16)
- Mark Newton (R, HD-127)
- Matt Hatchett (R, HD-155)
- Karen Mathiak (R, HD-82)
- Demetrius Douglas (D, HD-78)
- Patty Marie Stinson (D, HD-150)
Topics
- health insurance
- medical necessity reviews
- utilization review
- patient protections
- insurance regulation