Written by a parent, not a doctor. Nothing here is medical advice.

Childhood Cancer Lantern
Search Saved

Georgia program

Deadlines for treatment approval and drug exceptions

Georgia law sets decision deadlines for covered plans and allows exceptions to some required drug switches.

What it is

Georgia law sets decision deadlines for covered plans and allows exceptions to some required drug switches.

A clinic may need the insurer’s approval before treatment. Georgia’s deadlines start when the plan has all necessary information. Plan funding and the policy’s legal terms decide whether these state rules apply.

Eligibility rules
  • The seven-day deadline reaches plans an insurer sells in Georgia, the state employee plan and Medicaid health plans. A plan the employer funds itself follows federal rules instead.
  • HB 63’s step-therapy rules apply to health-benefit plans issued or renewed from January 1, 2020. The laws include the state employee health plan.
  • Self-insured ERISA employer plans are outside these state mandates. The benefits office can confirm funding type.
What you get
  • A seven-calendar-day decision clock, or 72 hours for an urgent complete request.
  • Protection for certain existing approvals when care starts or insurance changes.
  • Exceptions when a required drug is unsafe, ineffective or otherwise meets the law’s tests.
What the help includes
  • An approval used for the first service within 45 business days generally cannot be revoked. Exceptions include Schedule II drugs, billing error, fraud, material misrepresentation and lost coverage.
  • A new plan must honor a documented previous approval for at least 30 days of new coverage. That minimum does not promise a longer transition.
  • Drug exceptions include a contraindication or likely harm, or an expected lack of benefit for this child.
  • A prior trial on the current or immediately previous plan can qualify if it failed, lost effect or caused an adverse event. The prior drug can be in the same class or have the same mechanism.
  • A stable child can qualify when the doctor documents that a required switch is expected to be ineffective or harmful.
If you decide to apply
  1. Ask the clinic’s insurance navigator whether your plan follows Georgia’s approval deadlines.
  2. Have ready: the request, denial or delay letters, and the date the plan received everything.
  3. Ask the doctor to explain any drug-exception grounds and supply a previous approval after a plan change.

Clinic insurance navigator; DCH for Medicaid plan requirements; OCI for covered insurance complaints: 800-656-2298 · Official page ↗

After you ask
  • If the plan misses its deadline, the request usually counts as approved. Ask the clinic to get that in writing from the plan before treating a bill as covered.
Good to know

The clock starts with a complete request. Your clinic’s first submission date may be earlier.

Other details
  • Plan-specific appeal procedures still matter for state employee coverage. A rule about approval timing does not establish fertility-preservation coverage.
Official sources
Ask your social worker

“If treatment approval stalls or the plan wants a drug switch, which Georgia protections apply? What are the benefits and drawbacks of requesting an exception or review, and would you help us if appropriate?”

Why I’m asking: I want the care team to have a clear deadline and a way to explain why a required switch may not fit.

More background and detailed requirements
Additional program information and published rules

Who does what

The three parts, side by side. The agency decides; nobody on this page does.

You

Ask the clinic for the date the plan had everything, count the days, and call the plan and then the regulator when the clock passes.

Your social worker

The social worker connects you with the clinic's insurance navigator, who tracks each request.

The care team

Sends complete requests, marks urgent ones, and writes the step-therapy exception on one of the four grounds.

Who decides
The plan's review entity under Georgia law. Georgia's insurance regulator enforces it for Georgia-issued plans.
Ask the care team
“Was our prior-approval request sent complete, and on what date did the plan have everything? Georgia gives them 7 calendar days, or 72 hours if you mark it urgent.”

How to apply

First step: Ask the clinic's insurance navigator to send every prior-approval request complete and marked urgent when it is, and to record the date the plan had everything. Count 7 calendar days, or 72 hours if urgent.

  1. Have the clinic send the complete request at once and note the date the plan says it had everything.
  2. If the clock passes, call the plan, then Georgia's insurance regulator (800-656-2298).
  3. For a step-therapy demand, ask the oncologist to write the exception under one of the four grounds.

Official application / program page ↗

Where it starts: The clinic can identify the applicable approval clock and ask for written confirmation after a missed deadline. Certain process failures cause automatic authorization under Georgia law, subject to a limited statutory exception; the payer determines the complaint route.

What to gather

  • The request date and the plan's 'all information received' date
  • The denial or delay letters
  • For step therapy: the doctor's note on which of the four grounds applies

How long: 7 calendar days for a routine request and 72 hours for an urgent one, from the day the plan has everything.

What a yes looks like

An approval in writing by the deadline, and a step-therapy exception granted on the doctor's documentation.

What a no looks like, and the next move

A refusal has its own appeal deadline. Certain missed deadlines or process failures under Georgia law result in automatic authorization, subject to a limited exception. The team can request written confirmation and identify the correct regulator rather than assuming an unconfirmed bill is covered.

Watch out

  • The clocks run from the day the plan has all necessary information, not from the day the clinic first asked. Send everything at once and get that date.
  • Self-funded employer plans are outside these laws. One question to the benefits office settles it: fully insured or self-funded?
  • After a plan change the new plan honors a documented old approval for at least 30 days, not longer. Send the old approval to the new plan on day one.
  • SHBP Anthem HRA uses its plan appeal process. Its fertility exclusion and the new mandate have unresolved applicability; ask for a written plan-specific decision. Do not assume every SHBP option or teacher plan has the same terms.

The numbers and the rules

The arcane layer, kept on purpose. Checked September 10, 2026.

What it is worth

7 calendar days (routine) or 72 hours (urgent) to decide a prior approval once the plan has everything; no take-backs of an approval used within 45 business days; 30 days of honoring an old approval after a plan change; step-therapy exceptions in four situations.

  • $7 (effective January 1, 2023) — Routine prior-approval decision after the plan has all necessary information
  • $72 — Urgent prior-approval decision after the plan has all information
  • $45 (except a Schedule II controlled substance, billing error, fraud, material misrepresentation or loss of coverage) — Approval cannot be revoked if the first service happens within
  • $30 — New plan honors a documented prior approval for at least

Legal protection: Step-therapy exception when the required drug is contraindicated or would cause an adverse reaction or harm · Step-therapy exception when the required drug is expected to be ineffective for this patient · Step-therapy exception when the patient already tried that drug, or one in the same class or with the same mechanism, on the current or immediately preceding plan and it was stopped for lack of effect, diminished effect or an adverse event · Step-therapy exception when the patient is stable on a covered drug and the practitioner documents that the required switch is expected to be ineffective or harmful

What it costs the family: None.

The eligibility facts, as published

Plans bound
SB80 applies to specified Georgia policies and contracts, including SHBP and Medicaid care-management organizations, with its statutory effective dates. HB63 step-therapy scope is a separate check. DCH handles Medicaid-CMO requirements; OCI is not the regulator for every included payer.
Self funded
SB 80 says it is not the General Assembly's intent to regulate self-insured ERISA plans; HB 63 does not reach them under federal preemption
No revocation exceptions
Schedule II controlled substance, billing error, fraud, material misrepresentation, loss of coverage
Plan change honor days minimum
30

Decisions this site cannot make: Prior-authorization decision by the plan's utilization review entity · Step-therapy exception decision

Expect friction on: The 'all necessary information' date · Fully insured versus self-funded

The trap: The clocks start when the plan has all necessary information, so ask the clinic to send everything at once and get the date the plan says it had it. The 30-day honor period after a plan change needs the old approval documented to the new plan.

Where I read this

← Back to your options