Summary
Amends Georgia’s private review agent and utilization review framework to permit appropriate use of artificial intelligence, artificial intelligence systems, and software tools while prohibiting certain healthcare insurance coverage decisions from being based solely on those tools. Requires natural-person utilization review with clinical peer participation before adverse determinations and preserves clinical peer judgment.
Healthcare Implications
Directly constrains payer and utilization-review use of AI for medical-necessity or coverage decisions. Private review agents, utilization review entities, and payers using AI must keep qualified human review and clinical peer participation in the adverse-determination workflow, while regulators retain oversight through Georgia’s existing private review agent and utilization review framework.
Operational Implications
- Private review agents and utilization review entities may use AI or other software tools for permissible functions, but they may not issue or base adverse healthcare coverage determinations solely on those tools; a natural person/private review agent or utilization review entity must conduct the utilization review with clinical peer participation, and AI may not supersede clinical peer judgment.
- AI tools must be incorporated into utilization review activity under Georgia’s existing private review agent certification and regulatory framework, leaving compliance subject to Insurance Commissioner oversight and applicable utilization review standards.