HB 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

Under current Georgia law, before a private review agent or utilization review entity (the insurance side reviewers who decide whether treatment is medically necessary) can deny a claim, they must make an effort to discuss the case with the patient's treating provider. This bill spells out what that effort must actually look like: contacting the provider or their designee directly, using a callback phone system, or offering a public website where the provider can schedule a later call if no reviewer is available at the time. The bill also creates a new requirement for insurers that use prior authorization (advance approval before insurance will cover a treatment). Insurers must set up a program that reduces prior authorization requirements for providers who show strong performance and evidence based practices. Insurers choose their own criteria but must file a description of the program, its criteria, covered services, and participating provider counts with the state Department of Insurance every year starting no later than July 1, 2026. The law takes effect January 1, 2026, and applies to policies issued or renewed on or after that date.

• Requires reviewers questioning medical necessity to make specific documented efforts to reach the treating provider, including direct contact, a callback phone system, or a scheduling website.
• Bars an adverse coverage determination until that contact effort has been made during normal working hours.
• Requires health insurers using prior authorization to create a program that reduces those requirements for providers who perform well and follow evidence based medicine.
• Lets each insurer set its own criteria for which providers and services qualify for reduced prior authorization.
• Requires insurers to file an annual report on the program with the Department of Insurance starting no later than July 1, 2026, describing criteria, covered services, and participation numbers.
• Sets the law's effective date as January 1, 2026, applying to policies issued or renewed on or after that date.

Doctors and other treating health care providers whose patients face insurance reviews, private review agents and utilization review entities that conduct medical necessity reviews, health insurers that use prior authorization, and the Georgia Department of Insurance, which will collect and oversee the new annual filings.

Patients and doctors would get a clearer, more reliable process for insurers to consult a treating provider before denying care, potentially reducing denials made without real physician input. Providers with strong track records could also face fewer prior authorization hurdles, which may speed up approval for some treatments.

• Section 1 revises O.C.G.A. § 33-46-6(a)(5) to require reviewers to use direct contact, a callback telecommunications system, or a scheduling website to reach the treating provider before an adverse determination.
• Section 2 adds a new Code Section 33-46-20.1 requiring insurers using prior authorization to implement a program reducing those requirements for providers based on performance and evidence based practice.
• Subsection (b) lets insurers set their own participation criteria but requires a filing to the Department of Insurance describing the program, criteria, covered services, and participant counts.
• Subsection (c) sets a July 1, 2026 deadline for the first annual filing, with future filings governed by Commissioner rules and regulations.
• Section 3 sets the effective date as January 1, 2026, applying to policies or contracts issued, delivered, or renewed on or after that date.

1. 2025-05-14Effective Date 2026-01-01
2. 2025-05-14Act 303
3. 2025-05-14House Date Signed by Governor (Cámara de Representantes)
4. 2025-04-09House Sent to Governor (Cámara de Representantes)
5. 2025-04-04House Agreed Senate Amend or Sub (Cámara de Representantes)
6. 2025-04-02Senate Passed/Adopted By Substitute (Senado)
7. 2025-04-02Senate Third Read (Senado)
8. 2025-04-02Senate Taken from Table (Senado)

• Lee Hawkins (R, HD-027)Patrocinador principal
• Mark Newton (R, HD-127)
• Trey Kelley (R, HD-016)
• Deborah Silcox (R, HD-053)
• Sharon Cooper (R, HD-045)
• Michelle Au (D, HD-050)
• Kay Kirkpatrick (R, SD-032)

1. AprobadaVotación: Cámara de Representantes4 de marzo de 2025

   174 a favor, 0 en contra (4 sin votar, 2 ausentes)

   Passage: House Vote #153

2. AprobadaVotación: Senado2 de abril de 2025

   53 a favor, 0 en contra (1 sin votar, 2 ausentes)

   Passage By Substitute: Senate Vote #433

3. AprobadaVotación: Cámara de Representantes4 de abril de 2025

   162 a favor, 0 en contra (6 sin votar, 12 ausentes)

   Agree To Senate Substitute: House Vote #413

• health insurance
• prior authorization
• medical necessity reviews
• insurance regulation
• health care providers