---
title: HB 1236. Insurance; medical necessity of a healthcare service; provisions
collection: bills
id: 2025-2026/hb1236
cite_as: HB 1236, 2025-2026 Regular Session (Ga.)
canonical_url: https://georgiacommons.org/bills/2025-2026/hb1236
md_url: https://georgiacommons.org/bills/2025-2026/hb1236.md
text_url: https://georgiacommons.org/bills/2025-2026/hb1236/text
source_url: https://www.legis.ga.gov/legislation/72957
date: 2026-02-24
status: introduced
corpus_version: bills-2026-09-13
license: Public record of the Georgia General Assembly, via LegiScan; see about.md
publisher: Georgia Commons, an independent project of Georgia Civic Data. Not the State of Georgia. Not legal advice.
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omitted: votes and history
omitted_chars: 185
omitted_url: https://georgiacommons.org/bills/2025-2026/hb1236.md?full=1
bill_number: HB 1236
session: 2025-2026 Regular Session
session_slug: 2025-2026
chamber: House
bill_type: bill
status_date: 2026-02-06
last_action: House Committee Favorably Reported
sponsors:
- Trey Kelley
- Mark Newton
- James Hatchett
- Karen Mathiak
- Demetrius Douglas
- Patty Stinson
text_version: Introduced
has_text: true
legiscan_url: https://legiscan.com/GA/bill/HB1236/2025
upstream_id: 2111492
summaries_model: claude-sonnet-5
topic_tags:
- health insurance
- medical necessity reviews
- utilization review
- patient protections
- insurance regulation
---
# HB 1236. Insurance; medical necessity of a healthcare service; provisions
## Text
House Bill 1236
By: Representatives Kelley of the 16th, Newton of the 127th, Hatchett of the 155th, Mathiak
of the 82nd, Douglas of the 78th, and others
A BILL TO BE ENTITLED
AN ACT
To amend Code Section 33-46-6 of the Official Code of Georgia Annotated, relating to
requirements for certification, utilization of nationally recognized accreditation standards,
and website identifying nationally recognized accreditation entities, so as to provide that, in
cases where a private review agent or utilization review entity is questioning the medical
necessity of a healthcare service, a final determination on medical necessity must be agreed
to by a clinical peer licensed in this state; to provide for related matters; to provide for an
effective date and applicability; to repeal conflicting laws; and for other purposes.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:
SECTION 1.
Code Section 33-46-6 of the Official Code of Georgia Annotated, relating to requirements
for certification, utilization of nationally recognized accreditation standards, and website
identifying nationally recognized accreditation entities, is amended by revising paragraph (5)
of subsection (a) as follows:
"(5) In any instances where the private review agent or utilization review entity is
questioning the medical necessity of care a healthcare service, the treating health care
healthcare provider, or such provider's appropriately qualified designee, shall be able to
discuss the plan of treatment with a clinical peer licensed in this state and trained in a
related specialty and no adverse determination shall be made by the private review agent
or utilization review entity unless such determination is agreed to by such licensed
clinical peer and not until an effort has been made to discuss the patient's care with the
patient's treating healthcare provider, or such provider's appropriately qualified designee
who shall be familiar with the patient's case, during normal working hours. Such effort
shall include contacting the treating healthcare provider or his or her designee,
implementing a callback telecommunications system, or the use of a public website
whereby such provider or designee may elect to receive a scheduled communication at
a later time in the event that a clinical peer is not available. In the event of an adverse
determination, notice to the treating healthcare provider will must specify the reasons for
the review determination;"
SECTION 2.
This Act shall become effective on January 1, 2027, and shall apply to all policies or
contracts issued, delivered, issued for delivery, or renewed in this state on or after such date.
SECTION 3.
All laws and parts of laws in conflict with this Act are repealed.
## Summaries written by Georgia Commons
The following was written by claude-sonnet-5 from the text above and is not part of the bill. Quote the text, not the summary.
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.
### Plain-language summary
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 it 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.
## Status
- Status: Introduced (2026-02-06)
- Last action: House Committee Favorably Reported (2026-02-24)
- Sponsors: Trey Kelley, Mark Newton, James Hatchett, Karen Mathiak, Demetrius Douglas, Patty Stinson
- Official page: https://www.legis.ga.gov/legislation/72957
> The history, votes, and amendments (185 characters) are at https://georgiacommons.org/bills/2025-2026/hb1236.md?full=1