Summary
Amends Iowa health insurance and utilization review law to address health carrier standards of conduct, utilization review organization audits, prior authorizations, and AI use. The law allows utilization review organizations to use AI-based algorithms or systems for initial prior authorization review, but prohibits AI from serving as the sole basis for denying, delaying, or downgrading a medical-necessity prior authorization request. It also requires qualified reviewer or clinical peer involvement for prior-authorization denials or downgrades and sets provider notice, audit, appeal, and documentation requirements.
Healthcare Implications
Directly limits payer and utilization-review use of AI in prior authorization. AI can support initial review, but medical-necessity denials, delays, or downgrades must not be solely AI-based and must involve qualified clinical review with written reasons and appeal rights. The law affects health carriers, utilization review organizations, providers submitting prior authorization requests, covered persons, and the Iowa Insurance Commissioner.
Operational Implications
- Utilization review organizations may use an AI-based algorithm or system for initial review of prior authorization requests, but for medical-necessity requests they may not use AI as the sole basis to deny, delay, or downgrade the request; separate prior-authorization provisions require denials or downgrades to be made by a qualified reviewer or clinical peer and supported by written reasons, clinical/coverage criteria, appeal information, and reviewer attestations.