Summary
Regulates carriers’, PBMs’, and private review agents’ use of artificial intelligence, algorithms, or other software tools in utilization review. Requires determinations to account for an enrollee’s medical history and clinical circumstances; bars sole reliance on population‑level datasets; maintains clinician oversight; and sets documentation and appeal safeguards.
Healthcare Implications
Directly constrains automated prior authorization and medical‑necessity tools. Payers must implement guardrails, transparency, and human oversight; providers should expect clearer appeal documentation and be able to request human review. Aligns with national scrutiny of AI in utilization management and protects patients from algorithm‑only denials.
Operational Implications
- AI tools may not replace healthcare provider decisionmaking; final medical-necessity decisions made by clinicians.
- AI determinations must be based on individual medical history, individual clinical circumstances reported by provider, and other relevant clinical info; may not rely solely on group datasets.
- AI tools must be applied equitably; must not discriminate.
- Quarterly review of AI performance, use, and outcomes.
- Documentation/disclosure requirements for AI use in UR. Applies to carriers, PBMs, and private review agents.