Georgia CommonsHB 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
Enrolled version, the latest LegiScan holds · Last action May 14, 2025 · Passed
The text as LegiScan holds it, read from the PDF the legislature publishes with its margin line numbers, running heads, and page footers removed. Line breaks are joined into paragraphs here; no word is changed.
Underlined words are what the bill adds to current law and struck-through words are what it removes, as the printed bill shows them.
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 Annotated, relating to requirements for certification, utilization of nationally recognized accreditation standards, and website identifying nationally recognized accreditation entities, so as to detail the effort that shall be made by treating health care provider to respond to a private review agent or utility review entity's attempt to reach such provider to discuss the patient's care; to amend Chapter 46 of Title 33 of the Official Code of Georgia Annotated, relating to certification of private review agents, so as to provide for health insurers to implement and maintain a program that allows for the selective application of reductions in prior authorization requirements under certain circumstances; to provide for an annual filing; to provide for the promulgation of rules and regulations; 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, the treating health care provider, or such provider's appropriately qualified designee, shall be able to discuss the plan of treatment with a clinical peer trained in a related specialty and no adverse determination shall be made by the private review agent or utilization review entity until an effort has been made to discuss the patient's care with the patient's treating 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 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 provider will specify the reasons for the review determination;"
SECTION 2.
Chapter 46 of Title 33 of the Official Code of Georgia Annotated, relating to certification of private review agents, is amended by adding a new Code section to read as follows:
"33-46-20.1.
(a) Each insurer that utilizes prior authorization requirements shall implement and maintain a program that allows for the selective application of reductions in prior authorization requirements based on the stratification of healthcare providers' performance and adherence to evidence based medicine. Such program shall promote quality, affordable healthcare and reduce unnecessary administrative burdens for both the insurer and the healthcare provider.
(b) Criteria for participation by healthcare providers and the healthcare services included in the program shall be at the discretion of the insurer; provided, however, that such insurer shall submit to the department a filing concerning such program. Such filing shall include a full narrative description of the program, the criteria for participation in the program, a list of the procedures and services subject to the program, the number of healthcare providers participating in the program, and any other information deemed necessary by the department.
(c) No later than July 1, 2026, each insurer that utilizes prior authorization requirements shall make the filing provided for in subsection (b) of this Code section, and such filing shall be submitted annually in a form and manner provided for by rules and regulations promulgated by the Commissioner."
SECTION 3.
This Act shall become effective on January 1, 2026, and shall apply to all policies or contracts issued, delivered, issued for delivery, or renewed in this state on or after such date.
SECTION 4.
All laws and parts of laws in conflict with this Act are repealed.