25 LC 46 1247S
The Senate Committee on Rules offered the following
substitute to HB 197:
A BILL TO BE ENTITLED
AN ACT
To amend Code Section 33-46-6 of the Official Code of Georgia Annotated, relating to1
requirements for certification, utilization of nationally recognized accreditation standards,2
and website identifying nationally recognized accreditation entities, so as to detail the effort3
that shall be made by treating health care provider to respond to a private review agent or4
utility review entity's attempt to reach such provider to discuss the patient's care; to amend5
Chapter 46 of Title 33 of the Official Code of Georgia Annotated, relating to certification of6
private review agents, so as to provide for health insurers to implement and maintain a7
program that allows for the selective application of reductions in prior authorization8
requirements under certain circumstances; to provide for an annual filing; to provide for the9
promulgation of rules and regulations; to provide for related matters; to provide for an10
effective date and applicability; to repeal conflicting laws; and for other purposes.11
BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:12
SECTION 1.13
Code Section 33-46-6 of the Official Code of Georgia Annotated, relating to requirements14
for certification, utilization of nationally recognized accreditation standards, and website15
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identifying nationally recognized accreditation entities, is amended by revising paragraph (5)16
of subsection (a) as follows:17
"(5) In any instances where the private review agent or utilization review entity is18
questioning the medical necessity of care, the treating health care provider, or such19
provider's appropriately qualified designee, shall be able to discuss the plan of treatment20
with a clinical peer trained in a related specialty and no adverse determination shall be21
made by the private review agent or utilization review entity until an effort has been22
made to discuss the patient's care with the patient's treating provider, or such provider's23
appropriately qualified designee who shall be familiar with the patient's case, during24
normal working hours. Such effort shall include contacting the treating provider or his25
or her designee, implementing a callback telecommunications system, or the use of a26
public website whereby such provider or designee may elect to receive a scheduled27
communication at a later time in the event that a clinical peer is not available. In the28
event of an adverse determination, notice to the provider will specify the reasons for the29
review determination;"30
SECTION 2.31
Chapter 46 of Title 33 of the Official Code of Georgia Annotated, relating to certification of32
private review agents, is amended by adding a new Code section to read as follows:33
"33-46-20.1.34
(a) Each insurer that utilizes prior authorization requirements shall implement and35
maintain a program that allows for the selective application of reductions in prior36
authorization requirements based on the stratification of healthcare providers' performance37
and adherence to evidence based medicine. Such program shall promote quality,38
affordable healthcare and reduce unnecessary administrative burdens for both the insurer39
and the healthcare provider.40
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(b) Criteria for participation by healthcare providers and the healthcare services included41
in the program shall be at the discretion of the insurer; provided, however, that such insurer42
shall submit to the department a filing concerning such program. Such filing shall include43
a full narrative description of the program, the criteria for participation in the program, a44
list of the procedures and services subject to the program, the number of healthcare45
providers participating in the program, and any other information deemed necessary by the46
department.47
(c) No later than July 1, 2026, each insurer that utilizes prior authorization requirements48
shall make the filing provided for in subsection (b) of this Code section, and such filing49
shall be submitted annually in a form and manner provided for by rules and regulations50
promulgated by the Commissioner."51
SECTION 3.52
This Act shall become effective on January 1, 2026, and shall apply to all policies or53
contracts issued, delivered, issued for delivery, or renewed in this state on or after such date.54
SECTION 4.55
All laws and parts of laws in conflict with this Act are repealed.56
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