Senate Bill 602
By: Senators Parkes of the 7th, Mangham of the 55th, James of the 28th, Kemp of the 38th
and Harrell of the 40th
A BILL TO BE ENTITLED
AN ACT
To amend Article 2 of Chapter 46 of Title 33 of the Official Code of Georgia Annotated,
relating to prior authorization, so as to reform prior authorization and utilization review
requirements for healthcare plans; to provide for certain information to be provided to
healthcare providers at the time of notification of an adverse determination; to provide for
aggregate statistics of certain data; to provide for the Commissioner of Insurance to
summarize and report certain data; to provide for specific criteria as part of an insurer's
program not requiring prior authorizations under certain conditions; to provide for
definitions; to limit documentation for utilization review; to provide for technology
requirements for utilization review; to provide for prior authorizations to remain valid; to
provide for retroactive authorizations; to exempt certain healthcare services from prior
authorization; to revise prior authorization time responses; to provide for automatic
authorization; to provide for the chapter construction; 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.
Article 2 of Chapter 46 of Title 33 of the Official Code of Georgia Annotated, relating to
prior authorizations, is amended by revising Code Section 33-46-20, relating to prior
authorization requirements posted on website and statistical reporting, as follows:
"33-46-20.
(a) An insurer shall make any current prior authorization requirements readily accessible
on its website to healthcare providers. <del>Clinical criteria on which an adverse determination
is based shall be provided to the healthcare provider at</del> <ins>At</ins> the time of the notification <ins>of an
adverse determination, the healthcare provider shall be provided:
(1) The clinical criteria on which the adverse determination is based;
(2) Detailed reasoning for such determination;
(3) The national provider identifier, credentials, specialty, and board certification of the
reviewing physician; and
(4) The healthcare provider's rights and procedures for appeal.
</ins> (b) If an insurer intends either to implement a new prior authorization requirement or to
amend an existing requirement, such insurer shall ensure that the new or amended
requirement is not implemented unless such insurer's website has been updated to reflect
such addition or change. <ins>An insurer shall not retroactively deny coverage for a healthcare
service that received prior authorization.
</ins> (c) An insurer using prior authorization shall make aggregate statistics available per such
insurer and per its plans regarding prior authorization approvals and denials on its website
in a readily accessible format. The Commissioner shall determine the statistics required
in order to comply with this Code section in accordance with applicable state and federal
privacy laws. Such statistics shall include, but not be limited to, the following:
(1) <del>Approved or denied on</del> <ins>The total number of initial requests for prior authorization,
whether each</ins> initial request <ins>was approved or denied, and the approval and denial rates;
</ins> (2) Reason for denial;
(3) Whether appealed <ins>and the appeal rates;
</ins> (4) Whether approved or denied on appeal <ins>and the approval and denial rates;</ins> <del>and
</del> (5) Time between submission and response <ins>and the average response times;
(6) Whether the prior authorization, adverse determination, or appeal procedure was
compliant with time requirements of this chapter; and
(7) Whether the prior authorization, adverse determination, or appeal procedure was
compliant with procedural requirements of this chapter.
(d) The Commissioner shall include a summary of the prior authorization data required
under this Code section in the annual report required under Code Section 33-49-16."
</ins> SECTION 2.
Said article is further amended by revising subsection (b) of Code Section 33-46-20.1,
relating to program of selective application of reductions in prior authorization requirements,
as follows:
"(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 <del>such</del> <ins>each
insurer shall include in the program a provision under which such insurer shall not require
prior authorization from a healthcare provider for a specific healthcare service if, in the
prior 12 month period, the insurer has approved not less than 80 percent of such healthcare
provider's prior authorization requests for such healthcare service. Such exemption shall
remain in effect for not less than 12 months, unless the insurer determines there has been
fraud or material misrepresentation. Each</ins> 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."
SECTION 3.
Said article is further amended by revising subsection (d) and adding new subsections to
Code Section 33-46-21, relating to insurer responsibility for compliance, periodic reviews,
and evaluation of adverse determinations, to read as follows:
"(d) <ins>As used in this subsection, the term 'qualified healthcare provider' shall have the same
meaning as set forth in Code Section 33-46-22.</ins> Qualified healthcare <del>professionals
</del> <ins>providers</ins> shall administer the utilization review program and oversee utilization review
decisions. An initial screening of prior authorization requests may be completed without
providing the treating provider or other qualified healthcare <del>professional</del> <ins>provider</ins> with the
opportunity to speak with a clinical peer of the private review agent or utilization review
entity. Such an opportunity shall be provided, however, before an appeal. If a private
review agent or utilization review entity questions the medical necessity of a healthcare
service, such agent or entity shall notify the covered person's treating provider, or such
provider's appropriately qualified designee familiar with the patient's case, that medical
necessity is being questioned in accordance with the provisions of paragraph (5) of
subsection (a) of Code Section 33-46-6."
<ins>"(f) Any documentation requests under the utilization review program shall be limited to
information reasonably necessary to establish medical necessity. Duplicative and irrelevant
documentation shall not be required.
(g) Any utilization review program shall accept and respond to prior authorization requests
through secured electronic transmission standards for pharmacy transactions. Technology
not integrated into a healthcare provider's electronic health record shall not be deemed
compliant."
</ins> SECTION 4.
Said article is further amended by revising Code Section 33-46-22, relating to review of
appeals by appropriate healthcare provider, as follows:
"33-46-22.
A private review agent or utilization review entity shall ensure that all <ins>adverse
determinations are made and all</ins> appeals <ins>of adverse determinations</ins> are reviewed by <del>an
appropriate</del> <ins>a qualified</ins> healthcare <del>provider</del> <ins>provider. As used in this Code section, the term
'qualified healthcare provider' means a licensed physician</ins> who shall:
(1) Possess a current and valid nonrestricted license or maintain other appropriate legal
authorization;
(2) Be currently in active practice in the same or similar specialty and who typically
manages the medical condition or disease;
(3) Be knowledgeable of, and have experience providing, the healthcare service under
appeal;
(4) Not have been directly involved in making the adverse determination; and
(5) Consider all known clinical aspects of the healthcare service under review, including,
but not limited to, a review of all pertinent medical or other records provided to the
private review agent or utilization review entity by the covered person's healthcare
provider, any relevant records provided to such agent or entity by a facility, and any
medical or other literature provided to such agent or entity by the healthcare provider."
SECTION 5.
Said article is further amended by revising Code Section 33-46-23, relating to restrictions on
authorizations when service timely rendered, as follows:
"33-46-23.
<ins>(a)</ins> If <del>initial</del> healthcare services are performed within <del>45 business days</del> <ins>one year</ins> of
approval of prior authorization, the insurer shall not revoke, limit, condition, or restrict
such authorization, unless such prior authorization is for a Schedule II controlled substance
or there is a billing error, fraud, material misrepresentation, or loss of coverage.
<ins>(b) Except for ongoing medication therapy of chronic conditions as provided for in Code
Section 33-46-23.1, a prior authorization of a healthcare service shall remain valid for the
lesser of one year from the date the healthcare provider receives prior authorization, the
duration of the treatment of the condition of the covered person, or until the last day of
coverage under the covered person's healthcare plan, unless there is fraud or material
misrepresentation."
</ins> SECTION 6.
Said article is further amended by adding a new Code section to read as follows:
<ins>"33-46-23.2.
(a) As used in this Code section, the term 'retroactive authorization' means any written or
oral determination made by a claim administrator or an insurer, or any agent thereof, after
a covered person's receipt of a healthcare service that such service is a covered benefit
under the applicable plan and that any requirement of medical necessity or other
requirements imposed by such plan as prerequisites for payment for such service are
satisfied. The term 'agent' as used in this subsection shall not include an agent or agency
as defined in Code Section 33-23-1.
(b) A healthcare provider may submit a request for a retroactive authorization for a
healthcare service within ten days of rendering such service.
(c) A claim for coverage of a healthcare service shall not be denied solely for a healthcare
provider's failure to obtain prior authorization."
</ins> SECTION 7.
Said article is further amended by revising Code Section 23-46-24, relating to medically
necessary unanticipated emergency or urgent healthcare services, as follows:
"33-46-24.
<ins>(a)</ins> Prior authorization shall not be required for unanticipated emergency healthcare
services, urgent healthcare services, or covered healthcare services which are incidental
to the primary covered healthcare service and determined by the covered person's physician
or dentist to be medically necessary.
<ins>(b) Prior authorization shall not be required for medications for opioid use disorder for a
covered person under a healthcare plan."
</ins> SECTION 8.
Said article is further amended by revising Code Section 33-46-26, relating to timely
notification of prior authorization or adverse determination, as follows:
"33-46-26.
Effective January 1, 2022, until December 31, 2022, if an insurer requires prior
authorization of a healthcare service, a private review agent or utilization review entity
shall notify the covered person's healthcare provider, or such provider's appropriately
qualified designee, of any prior authorization or adverse determination within 15 calendar
days of obtaining all necessary information to make such authorization or adverse
determination. Effective January 1, 2023, if an insurer requires prior authorization of a
healthcare service, a private review agent or utilization review entity shall notify the
covered person's healthcare provider, or such provider's appropriately qualified designee,
of any prior authorization or adverse determination within <del>7 calendar days</del> <ins>48 hours</ins> of
obtaining all necessary information to make such authorization or adverse determination."
SECTION 9.
Said article is further amended by revising Code Section 33-46-27, relating to notification
time for prior authorization or adverse determination, as follows:
"33-46-27.
A private review agent or utilization review entity shall render a prior authorization or
adverse determination concerning urgent healthcare services and notify such person's
healthcare provider, or such provider's appropriately qualified designee, of that prior
authorization or adverse determination no later than <del>72 hours</del> <ins>24 hours</ins> after receiving all
information needed to complete the review of the requested healthcare services."
SECTION 10.
Said article is further amended by revising subsection (a) of Code Section 33-46-28, relating
to honoring prior authorizations, as follows:
"(a) Upon receipt of information documenting a prior authorization from a covered person
or from a covered person's healthcare provider, a private review agent or utilization review
entity, for at least the initial <del>30</del> <ins>90</ins> days of such person's new coverage, shall honor a prior
authorization for a covered healthcare service granted to him or her from a previous private
review agent or utilization review entity even if approval criteria or products of a
healthcare plan have changed or such person is covered under a new healthcare plan, so
long as the former criteria, products, or plans are not binding upon a new insurer."
SECTION 11.
Said article is further amended by revising Code Section 33-46-29, relating to noncompliance
resulting in automatic authorization, as follows:
"33-46-29.
Each violation by a private review agent or utilization review entity of deadline or other
requirements specified in this chapter shall result in the automatic authorization of
healthcare services under review by such private review agent or utilization review entity
if such noncompliance is related to such services. <del>Notwithstanding the foregoing,
noncompliance based on a de minimis violation that does not cause, or is not likely to
</del>
<del>cause, prejudice or harm to the covered person shall not result in the automatic
authorization of such healthcare services, so long as the insurer demonstrates that the
violation occurred due to good cause or due to matters beyond the control of the insurer
and that such violation occurred in the context of an ongoing good faith exchange of
information between the insurer and the covered person, or, if applicable, the covered
person's healthcare provider or authorized representative."
</del> SECTION 12.
Said article is further amended by revising Code Section 33-46-32, relating to
Commissioner's authority not reduced, as follows:
"33-46-32.
Nothing in this chapter shall be construed as:
<ins>(1) Mandating coverage of any specific healthcare service;
(2) Granting the Commissioner authority to determine covered benefits;
(3) Altering the medical necessity standards of a healthcare plan, except as expressly
provided;
(4) Reducing the Commissioner's authority, including, but not limited to, conducting
market conduct examinations and imposing monetary penalties for violations of any
provisions of this title; or
(5) Reducing</ins> <del>reducing</del> the authority of the commissioner of community health."
SECTION 13.
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 14.
All laws and parts of laws in conflict with this Act are repealed.