--- title: HB 197. 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 collection: bills id: 2025-2026/hb197 cite_as: HB 197, 2025-2026 Regular Session (Ga.) canonical_url: https://georgiacommons.org/bills/2025-2026/hb197 md_url: https://georgiacommons.org/bills/2025-2026/hb197.md text_url: https://georgiacommons.org/bills/2025-2026/hb197/text source_url: https://www.legis.ga.gov/legislation/69713 date: 2025-05-14 status: passed corpus_version: bills-2026-08-28 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. up: https://georgiacommons.org/bills/2025-2026.md previous: https://georgiacommons.org/bills/2025-2026/hb196.md next: https://georgiacommons.org/bills/2025-2026/hb198.md index: https://georgiacommons.org/bills/index.md omitted: votes and history omitted_chars: 1382 omitted_url: https://georgiacommons.org/bills/2025-2026/hb197.md?full=1 bill_number: HB 197 session: 2025-2026 Regular Session session_slug: 2025-2026 chamber: House bill_type: bill status_date: 2025-05-14 last_action: Effective Date 2026-01-01 sponsors: - Lee Hawkins - Mark Newton - Trey Kelley - Deborah Silcox - Sharon Cooper - Michelle Au - Kay Kirkpatrick text_version: Enrolled has_text: true legiscan_url: https://legiscan.com/GA/bill/HB197/2025 upstream_id: 1949616 summaries_model: claude-sonnet-5 topic_tags: - health insurance - prior authorization - medical necessity reviews - insurance regulation - patient care --- # HB 197. 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 ## Text 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 - ## 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. Georgia House Bill 197 spells out how hard health insurers' review agents must try to reach a patient's doctor before denying care, and requires insurers to report programs that ease prior authorization rules for high-performing providers. ### Plain-language summary Under current Georgia law, before an insurer's private review agent can deny coverage for medical necessity reasons, some effort must be made to discuss the case with the treating provider. This bill spells out exactly what that effort must look like: contacting the provider directly, using a callback phone system, or offering a public website where the provider can schedule a later call if a clinical peer isn't immediately available. The bill also creates a new requirement for insurers that use prior authorization (the practice of requiring advance approval before covering certain care). Insurers must set up programs that reduce prior authorization requirements for providers who show strong performance and follow evidence based medicine. Insurers must file details of these programs annually with the Georgia Department of Insurance, starting no later than July 1, 2026. The law takes effect January 1, 2026, and applies to policies issued or renewed on or after that date. ### What it does - Requires review agents to make specific documented efforts (direct contact, callback system, or scheduling website) to reach a treating provider before denying coverage for medical necessity. - Requires insurers using prior authorization to create programs that reduce those requirements for providers who perform well and follow evidence based medicine. - Requires insurers to file a detailed annual description of these reduction programs with the Georgia Department of Insurance, including participation criteria and provider counts. - Sets July 1, 2026 as the deadline for the first annual filing and directs the Insurance Commissioner to create rules governing the filing process. - Sets the law's effective date as January 1, 2026, applying to insurance policies and contracts issued or renewed on or after that date. ### Who it affects Health insurers and their private review agents or utilization review entities, treating health care providers such as doctors and their designees, patients whose care is subject to prior authorization or medical necessity review, and the Georgia Department of Insurance, which oversees the new filings. ### Why it matters Patients facing insurance denials would benefit from clearer rules requiring insurers to actually try reaching their doctor before an adverse decision. Providers with strong track records could face fewer prior authorization hurdles, potentially speeding up patient care and reducing paperwork for both providers and insurers. ### Key provisions - Section 1 revises O.C.G.A. § 33-46-6(a)(5) to require that review agents' effort to reach a treating provider include direct contact, a callback telecommunications system, or a scheduling website option. - Section 1 requires that any adverse determination notice specify the reasons for the review decision. - Section 2 adds new O.C.G.A. § 33-46-20.1, requiring insurers using prior authorization to implement programs reducing those requirements based on provider performance and evidence based medicine. - Section 2 requires insurers to file a narrative description of the program, participation criteria, covered procedures, and participating provider counts with the Department of Insurance. - Section 2 sets July 1, 2026 as the deadline for the first annual filing, with future filings governed by Commissioner rules. - Section 3 sets the effective date as January 1, 2026, applying to policies issued, delivered, or renewed on or after that date. ## Status - Status: Passed (2025-05-14) - Last action: Effective Date 2026-01-01 (2025-05-14) - Sponsors: Lee Hawkins, Mark Newton, Trey Kelley, Deborah Silcox, Sharon Cooper, Michelle Au, Kay Kirkpatrick - Official page: https://www.legis.ga.gov/legislation/69713 > The history, votes, and amendments (1,382 characters) are at https://georgiacommons.org/bills/2025-2026/hb197.md?full=1