HB1236: HB1236 Insurance; medical necessity of a healthcare service; provisions

Georgia law already requires private review agents and utilization review entities, the companies insurers use to decide whether a medical treatment is necessary, to let a treating doctor discuss a case with a clinical peer before denying coverage. This bill tightens that rule by adding a requirement that any final adverse determination on medical necessity must be agreed to by a clinical peer who is licensed in Georgia and trained in a related specialty. The bill amends O.C.G.A. § 33-46-6, which governs certification and accreditation standards for these review entities. It keeps existing requirements that reviewers try to discuss a patient's treatment plan with the treating provider during normal working hours, using methods like phone calls, a callback system, or a public website for scheduling. The changes would take effect January 1, 2027, and would apply to insurance policies and contracts issued, delivered, or renewed in Georgia on or after that date.

• Requires that any adverse determination on the medical necessity of a healthcare service be agreed to by a clinical peer licensed in Georgia before it becomes final.
• Keeps the existing requirement that the treating healthcare provider or their designee be able to discuss the treatment plan with a clinical peer trained in a related specialty.
• Preserves the rule that reviewers must attempt to contact the treating provider during normal working hours before making an adverse determination, using methods like phone calls or a scheduling website.
• Requires that any notice of an adverse determination sent to the treating provider specify the reasons for the decision.
• Sets the effective date as January 1, 2027, applying to insurance policies and contracts issued or renewed in Georgia on or after that date.

Health insurers and the private review agents or utilization review companies they use to evaluate medical necessity, along with treating healthcare providers such as doctors and their designees, and patients whose care is subject to these coverage reviews in Georgia.

If enacted, patients could see fewer or different denials of coverage, since insurers could not finalize a medical necessity denial without sign off from a Georgia-licensed clinical peer. This affects how quickly and on what basis insurance decisions about treatment are made.

• Section 1 amends paragraph (5) of subsection (a) of O.C.G.A. § 33-46-6 to add the clinical peer agreement requirement for adverse determinations on medical necessity.
• Section 1 retains the requirement that treating providers be able to discuss the plan of treatment with a clinical peer licensed in Georgia and trained in a related specialty.
• Section 1 keeps the mandate that review entities attempt to contact the treating provider before making a determination, through direct contact, a callback system, or a scheduling website.
• Section 1 requires that notice of an adverse determination sent to the treating provider specify the reasons for the decision.
• Section 2 sets the effective date as January 1, 2027, applying to policies and contracts issued, delivered, or renewed in Georgia on or after that date.
• Section 3 repeals any conflicting laws.

1. 2026-02-24House Committee Favorably Reported (House)
2. 2026-02-10House Second Readers (House)
3. 2026-02-09House First Readers (House)
4. 2026-02-06House Hopper (House)

• Trey Kelley (R, HD-016)Primary sponsor
• Mark Newton (R, HD-127)
• James Hatchett (R, HD-155)
• Karen Mathiak (R, HD-082)
• Demetrius Douglas (D, HD-078)
• Patty Stinson (D, HD-150)

• health insurance
• medical necessity reviews
• utilization review
• insurance regulation
• patient care denials