Summary
Prohibits certain downcoding practices in health insurance claims and restricts the use of automated processes, systems, or tools, including artificial intelligence, in claim submission and adjudication without appropriate review.
Healthcare Implications
Would directly impact payer and provider use of AI in claims processing by limiting automated downcoding and requiring human oversight in utilization management workflows. Health plans and providers will need to adjust claims review, documentation, and audit processes to ensure compliance.
Operational Implications
- AI may not be sole basis for downcoding a claim based on medical necessity without medical record review.
- Providers may not use AI/automated tools to submit health benefit claims without human review.
- Insurers must disclose in easily accessible and readable manner when AI is used to make adverse PA determinations or downcode claims. Excludes Medicaid managed care.