Summary
Comprehensive prior-authorization reform with explicit AI provisions: adverse determinations require physician or clinical-peer review, AI may not be the sole basis for medical-necessity decisions, AI use must be disclosed to regulators, providers, enrollees, and the public, and automated utilization-management systems are subject to audit.
Healthcare Implications
Requires human clinical accountability in utilization management while adding specific transparency and audit obligations for insurer and UR-agent AI use. Payers and vendors must disclose AI use and prepare for regulatory review; providers and patients gain clearer protections against AI-only adverse determinations.
Operational Implications
- Adverse PA determinations must be made by a physician (or clinical peer); AI may not be sole basis for medical-necessity decisions (Sec. 12).
- Insurer must disclose AI use to department, each network provider, each enrollee, and on public website (Sec. 12).
- Department may audit UR agent's automated UM system at any time, including via third-party contractor (Sec. 12).