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.