WHAT THIS BILL REGULATES · 2 REQUIREMENT TYPES
How Is This Bill Enforced
Verbatim statutory text on the left; plain-language analysis and a per-section checklist on the right. Numbered markers cross-link to the matching checklist row.
(1) As used in this section, the term: (a) "AlgorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a)" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results. (b) "Artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b)" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments. (c) "Machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c)" means an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b) that has the ability to learn from provided data without being explicitly programmed. (d) "Qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d)" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.
(2) A carrier may use an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c) to assist in processing claims, including generating recommendations to approve or deny a claim or a portion of a claim, in accordance with this section.
(3)–(4) 1 A decision to reduce a claim payment or deny a claim or a portion of a claim may not be made solely on the basis of an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c). A carrier's decision to reduce a claim payment or deny a claim or a portion of a claim must be made by a qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d). (4) If an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c) assists in processing a claim, the qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d) must do all of the following before reducing a claim payment or denying the claim or a portion of the claim: (a) Analyze the facts of the claim and the terms of the insurance policy independently of any artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c), or algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a). (b) Review the accuracy of any output generated by such a system or algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a). (c) Determine that the claim or portion of the claim is not payable under the terms of the insurance policy and should be denied or that the claim payment should be reduced.
(5) 3 A carrier shall maintain detailed records of the actions of qualified human professionalsQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d) who are required to perform the actions under subsection (4), including: (a) The name, the title, the business address, and the unique identifier associated with the name of the qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d) who made the decision to reduce the claim payment or deny the claim or a portion of the claim. (b) The date and time of the qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d)'s decision. (c) Documentation of the basis for the reduction of the claim payment or denial of the claim or a portion of the claim, including any information provided by an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c).
(6) 2 In all written denial communications to an injured employee, a carrier shall include: (a) An e-mail address, a telephone number, a business address, and a unique identifier, in lieu of the name of the qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d) who made the decision to reduce the claim payment or deny the claim or a portion of the claim; and (b) A written statement affirming that an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c) did not serve as the sole basis for determining whether to reduce the claim payment or deny the claim or a portion of the claim.
(7) 4 A carrier that uses an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c) as part of its claims-handling process shall detail in its claims-handling manual the manner in which such algorithmsAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a) or systems are to be used and the manner in which the carrier complies with this section.
(8)–(10) The department may conduct examinations and investigations it deems necessary to verify compliance with this section. (9) The department may adopt rules to implement this section. (10) Failure to comply with this section shall be considered a violation of this chapter and is subject to penalties as provided for in s. 440.525.
Section 440.131 applies the bill's mandatory human-review framework to workers' compensation carriers. Carriers may use algorithms, AI, or machine learning to assist claims processing — including generating approve/deny recommendations — but a decision to reduce or deny a claim cannot rest solely on such tools and must be made by a qualified human professional who independently analyzes the facts and policy terms, reviews the AI output for accuracy, and makes the adverse determination.
The section also imposes contemporaneous recordkeeping (reviewer identity, date/time, and basis), specific content requirements for written denial communications to injured employees (a contact channel and unique identifier in lieu of the reviewer's name, plus a written affirmation that AI was not the sole basis), and a claims-handling-manual documentation duty. Enforcement runs through the Department of Financial Services examinations and investigations, with violations subject to s. 440.525 penalties.
(1) As used in this section, the term: (a) "AlgorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a)" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results. (b) "Artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b)" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments. (c) "Machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c)" means an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b) that has the ability to learn from provided data without being explicitly programmed. (d) "Qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d)" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.
(2) An insurer may use an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a), artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), or machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c) to assist in processing claims, including generating recommendations to approve or deny a claim or a portion of a claim, in accordance with this section.
(3)–(4) 5 A decision to reduce a claim payment or deny a claim or a portion of a claim may not be made solely on the basis of an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c). An insurer's decision to reduce a claim payment or deny a claim or a portion of a claim must be made by a qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d). (4) If an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c) assists in processing a claim, the qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d) must do all of the following before reducing a claim payment or denying the claim or a portion of the claim: (a) Analyze the facts of the claim and the terms of the insurance policy independently of any artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c), or algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a). (b) Review the accuracy of any output generated by such a system or algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a). (c) Determine that the claim or portion of the claim is not payable under the terms of the insurance policy and should be denied or that the claim payment should be reduced.
(5) 7 An insurer shall maintain detailed records of the actions of qualified human professionalsQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d) who are required to perform the actions under subsection (4), including: (a) The name, the title, the business address, and the unique identifier associated with the name of the qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d) who made the decision to reduce the claim payment or deny the claim or a portion of the claim. (b) The date and time of the qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d)'s decision. (c) Documentation of the basis for the reduction of the claim payment or denial of the claim or a portion of the claim, including any information provided by an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c).
(6) 6 In all written denial communications to an insured, an insurer shall include: (a) An e-mail address, a telephone number, a business address, and a unique identifier, in lieu of the name of the qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d) who made the decision to reduce the claim payment or deny the claim or a portion of the claim; and (b) A written statement affirming that an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c) did not serve as the sole basis for determining whether to reduce the claim payment or deny the claim or a portion of the claim.
(7) 8 An insurer that uses an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c) as part of its claims-handling process shall detail in its claims-handling manual the manner in which such algorithmsAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a) or systems are to be used and the manner in which the insurer complies with this section.
(8)–(9) The office may conduct market conduct examinations and investigations it deems necessary to verify compliance with this section. (9) The commission may adopt rules to implement this section.
Section 627.4263 applies the same mandatory human-review framework to insurers regulated under the Florida Insurance Code. Insurers may use algorithms, AI, or machine learning to assist in processing claims and generate approve/deny recommendations, but no claim reduction or denial may rest solely on the AI output — every adverse determination must be made by a qualified human professional after independent analysis, accuracy review, and substantive determination.
The section parallels s. 440.131 in imposing recordkeeping, written denial-communication content, and claims-handling-manual documentation duties. Enforcement runs through the Office of Insurance Regulation via market conduct examinations, with rulemaking authority vested in the Financial Services Commission. Unlike s. 440.131, this section does not cross-reference a specific penalty statute.
(1) As used in this section, the term: (a) "AlgorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a)" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results. (b) "Artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b)" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments. (c) "Machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c)" means an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b) that has the ability to learn from provided data without being explicitly programmed. (d) "Qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d)" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.
(2) A health maintenance organization may use an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c) to assist in processing claims, including generating recommendations to approve or deny a claim or a portion of a claim, in accordance with this section.
(3)–(4) 9 A decision to reduce a claim payment or deny a claim or a portion of a claim may not be made solely on the basis of an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a), artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), or machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c). A health maintenance organization's decision to reduce a claim payment or deny a claim or a portion of a claim must be made by a qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d). (4) If an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c) assists in processing a claim, the qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d) must do all of the following before reducing a claim payment or denying the claim or a portion of the claim: (a) Analyze the facts of the claim and the terms of the health maintenance contract independently of any artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c), or algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a). (b) Review the accuracy of any output generated by such a system or algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a). (c) Determine that the claim or portion of the claim is not payable under the terms of the health maintenance contract and should be denied or that the claim payment should be reduced.
(5) 11 A health maintenance organization shall maintain detailed records of the actions of qualified human professionalsQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d) who are required to perform the actions under subsection (4), including: (a) The name, the title, the business address, and the unique identifier associated with the name of the qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d) who made the decision to reduce the claim payment or deny the claim or a portion of the claim. (b) The date and time of the qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d)'s decision. (c) Documentation of the basis for the reduction of the claim payment or denial of the claim or a portion of the claim, including any information provided by an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c).
(6) 10 In all written denial communications to a subscriber, a health maintenance organization shall include: (a) An e-mail address, a telephone number, a business address, and a unique identifier, in lieu of the name of the qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. §§ 440.131(1)(d), 627.4263(1)(d), 641.31091(1)(d) who made the decision to reduce the claim payment or deny the claim or a portion of the claim; and (b) A written statement affirming that an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c) did not serve as the sole basis for determining whether to reduce the claim payment or deny the claim or a portion of the claim.
(7) 12 A health maintenance organization that uses an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. §§ 440.131(1)(b), 627.4263(1)(b), 641.31091(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. §§ 440.131(1)(c), 627.4263(1)(c), 641.31091(1)(c) as part of its claims-handling process shall detail in its claims-handling manual the manner in which such algorithmsAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. §§ 440.131(1)(a), 627.4263(1)(a), 641.31091(1)(a) or systems are to be used and the manner in which the health maintenance organization complies with this section.
(8)–(9) The office may conduct market conduct examinations and investigations or use any method it deems necessary to verify compliance with this section. (9) The commission may adopt rules to implement this section.
Section 641.31091 applies the bill's mandatory human-review framework to health maintenance organizations (HMOs). It mirrors the s. 440.131 and s. 627.4263 obligations but is the bill's clearest healthcare-coverage application: HMOs may use algorithms, AI, or machine learning to generate approve/deny recommendations on member claims, but no decision to reduce or deny a claim or portion may be made solely on the basis of such tools, and every adverse determination must be made by a qualified human professional.
HMOs face the same independent-analysis, accuracy-review, recordkeeping, denial-communication-attestation, and claims-handling-manual documentation duties. Enforcement runs through the Office of Insurance Regulation via market conduct examinations and Financial Services Commission rulemaking.