Relating to utilization review organizations’ use of artificial intelligence, prior authorization determinations and exemptions, and prepayment audits, and including applicability provisions

This bill relates to utilization review organizations’ use of artificial intelligence, prior authorization determinations and exemptions, and prepayment audits. DIVISION I —— PRIOR AUTHORIZATION —— USE OF ARTIFICIAL INTELLIGENCE AND PEER REVIEW. _____ a health care service (service) based on medical necessity, a URO shall not use an artificial intelligence-based algorithm as the sole basis for a decision to deny, delay, or downgrade the prior authorization request. “Downgrade” is defined in the bill. A URO shall not deny or downgrade a request for prior authorization unless: (1) the decision is made by a qualified reviewer or clinical peer, (2) the URO provides the health care provider (provider) requesting prior authorization a written statement citing the reasons for the decision, explaining the appeals process, and a written attestation as described by the bill. If a request for prior authorization is denied, the URO shall notify the provider within seven days and conduct a consultation as described by the bill. “Clinical peer” and “qualified reviewer” are defined in the bill. If a URO’s decision to deny or downgrade a request for prior authorization is appealed by the requesting provider or covered person, the appeal shall be conducted by a qualified reviewer or clinical peer who was not involved in the initial denial or downgrade. When conducting an appeal of a request for prior authorization, the qualified reviewer or clinical peer shall consider the known clinical aspects of the services under review, including but not limited to medical records relevant to the medical condition and any relevant medical literature submitted by the provider. The commissioner of insurance (commissioner) may adopt rules to administer this division of the bill. This division of the bill applies to requests for prior authorization made before January 1, 2027, if the request has not been finally determined on or before that date, and requests for prior authorization made on or after January 1, 2027. DIVISION II —— PRIOR AUTHORIZATION —— CANCER-RELATED EXEMPTIONS. _____ review requirements on, a covered person for a cancer-related screening or cancer-related preventative service if the screening or service is recommended by the covered person’s health care professional based on the most recently updated national comprehensive cancer network clinical practice guidelines in oncology. The commissioner may adopt rules to administer this division of the bill. This division of the bill applies to health benefit plans delivered, issued for delivery, continued, or renewed on or after January 1, 2027; and requests for prior authorization for a cancer-related screening or cancer-related preventative health care service if the screening or service is recommended by the covered person’s health care professional, the request is made before January 1, 2027, and the request has not been finally determined on or before that date. DIVISION III —— UTILIZATION REVIEW ORGANIZATIONS —— PREPAYMENT AUDITS. A URO that conducts a prepayment audit shall notify the provider that submitted the claim of the initiation of the prepayment audit no later than days after the carrier selects the claim for prepayment audit. “Prepayment audit” is defined by the bill. A URO shall complete a prepayment audit and issue a determination on the claim to the provider no later than days after the URO receives all requested documentation regarding the claim from the provider. A provider that submitted a claim that is the subject of a prepayment audit and that receives an adverse determination regarding the claim may appeal the determination no later than days after the provider receives the determination. A URO shall consider an appeal and issue a final determination on the claim no later than calendar days after receiving notice of an appeal. If a URO violates the bill, the claim shall be automatically approved by the URO and promptly paid, including interest. _____ this division of the bill. This division of the bill applies to prepayment audits initiated on or after January 1, 2027.