Summary
Requires health carriers conducting utilization review to use a clinical peer to evaluate the clinical appropriateness of an adverse determination and prohibits substituting artificial intelligence or another algorithm for that clinical-peer review.
Healthcare Implications
Preserves qualified human clinical review in adverse medical-necessity and utilization-review decisions. Health carriers must ensure that AI and algorithmic tools support rather than replace the clinical peer responsible for evaluating an adverse determination.
Operational Implications
- Effective January 1, 2026, each health carrier must use a clinical peer—not AI or another algorithm in place of that peer—to evaluate the clinical appropriateness of an adverse determination in its utilization review program.