(1) Each health insurer and utilization review organization shall ensure that the artificial intelligence, algorithm or other software tool used to review and approve, modify and delay or deny requests by providers: (A) Makes a determination based on the following information, as applicable: (i) An enrollee's medical or other clinical history; (ii) individual clinical circumstances as presented by the requesting healthcare provider; and (iii) other relevant clinical information contained in the enrollee's medical or other clinical record; (B) does not make a determination based solely on a group dataset; (2) Notwithstanding the provisions of paragraph (1), the artificial intelligence, algorithm or other software tool shall not deny, delay or modify healthcare services based in whole or in part on medical necessity. A determination of medical necessity shall be made only by a licensed physician or a licensed healthcare professional who is competent to evaluate the specific clinical issues involved in the healthcare services requested by the healthcare provider by reviewing and considering such healthcare provider's recommendation, the enrollee's medical or other clinical history, as applicable, and individual clinical circumstances.

No individual, other than a licensed physician or a licensed healthcare professional who is competent to evaluate the specific clinical issues involved in the healthcare services requested by the provider, shall deny or modify requests for authorization of healthcare services for an enrollee for reasons of medical necessity.

Each health insurer and utilization review organization shall ensure that the artificial intelligence, algorithm or other software tool used to review and approve, modify and delay or deny requests by providers: (C) does not supplant healthcare provider decision-making; (D) does not discriminate, directly or indirectly, against enrollees in violation of state or federal law; (E) is fairly and equitably applied, in accordance with any applicable regulations or guidance issued by the United States department of health and human services; (F) is periodically reviewed and revised to maximize accuracy and reliability; (G) uses patient data in compliance with the health insurance portability and accountability act of 1996, public law 104-191; and (H) does not directly or indirectly cause harm to the enrollee.

(e) Each health insurer subject to this act shall establish written policies and procedures that: (1) Describe the process by which the health benefit plan prospectively, retrospectively or concurrently reviews and approves, modifies and delays or denies requests, based in whole or in part on medical necessity, by healthcare providers of healthcare services for health benefit plan enrollees; and (2) require decisions to be based on the medical necessity of proposed healthcare services are consistent with criteria or guidelines that are supported by clinical principles and processes.

(f) (1) Each health insurer subject to this act shall file with the department such health insurer's policies and procedures establishing the process by which such health insurer prospectively, retrospectively or concurrently reviews and approves, modifies and delays or denies requests, based in whole or in part on medical necessity, by providers of healthcare services for health benefit plan enrollees. (2) Pursuant to paragraph (1), such policies and procedures shall ensure that healthcare decisions based on the medical necessity of proposed healthcare services are consistent with criteria or guidelines that are supported by clinical principles and processes. (3) Each health insurer shall disclose such policies and procedures to insureds, healthcare providers and the public upon request.