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

26 LC 60 0237 House Bill 1236 By: Representatives Kelley of the 16th, Newton of the 127th, Hatchett of the 155th, Mathiak of the 82nd, Douglas of the 78th, 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 provide that, in3 cases where a private review agent or utilization review entity is questioning the medical4 necessity of a healthcare service, a final determination on medical necessity must be agreed5 to by a clinical peer licensed in this state; to provide for re lated matters; to provide for an6 effective date and applicability; to repeal conflicting laws; and for other purposes.7 BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:8 SECTION 1.9 Code Section 33-46-6 of the Official Code of Georgia Annotated, relating to requirements10 for certification, utilization of nationally recognized accredi tation standards, and website11 identifying nationally recognized accreditation entities, is amended by revising paragraph (5)12 of subsection (a) as follows:13 "(5) In any instances where the private review agent or utiliza tion review entity is14 questioning the medical necessity of care a healthcare service, the treating health care15 healthcare provider, or such provider's appropriately qualified designee, shall be able to16 H. B. 1236 - 1 - 26 LC 60 0237 discuss the plan of treatment with a clinical peer licensed in this state and trained in a17 related specialty and no adverse determination shall be made by the private review agent18 or utilization review entity unless such determination is agree d to by such licensed19 clinical peer and not until an effort has been made to discuss the patient's care with the20 patient's treating healthcare provider, or such provider's appropriately qualified designee21 who shall be familiar with the patient's case, during normal working hours. Such effort22 shall include contacting the treating healthcare provider or his or her designee,23 implementing a callback telecommunications system, or the use o f a public website24 whereby such provider or designee may elect to receive a scheduled communication at25 a later time in the event that a clinical peer is not available . In the event of an adverse26 determination, notice to the treating healthcare provider will must specify the reasons for27 the review determination;"28 SECTION 2.29 This Act shall become effective on January 1, 2027, and shall a pply to all policies or30 contracts issued, delivered, issued for delivery, or renewed in this state on or after such date.31 SECTION 3.32 All laws and parts of laws in conflict with this Act are repealed.33 H. B. 1236 - 2 -