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 <del>care</del> <ins>a healthcare service,</ins> the treating <del>health care
</del> <ins>healthcare</ins> provider, or such provider's appropriately qualified designee, shall be able to
discuss the plan of treatment with a clinical peer <ins>licensed in this state and</ins> trained in a
related specialty and no adverse determination shall be made by the private review agent
or utilization review entity <ins>unless such determination is agreed to by such licensed
clinical peer and not</ins> until an effort has been made to discuss the patient's care with the
patient's treating <ins>healthcare</ins> 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 <ins>healthcare</ins> provider or his or her designee,
implementing a callback telecommunications system, or the use of a <del>public</del> 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 <ins>treating healthcare</ins> provider <del>will</del> <ins>must</ins> 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.