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. <ins>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.</ins> 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:
<ins>"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.
</ins>
<ins>(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."
</ins> 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.