WHAT THIS BILL REGULATES · 1 REQUIREMENT TYPE
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) "Adverse determinationAdverse determination"Adverse determination" means a determination by a utilization review agent that health care services provided or proposed to be provided to a patient are not medically necessary or appropriate, or are experimental or investigational;36 O.S. § 6550(1)" means a determination by a utilization review agentUtilization review agentThe bill does not define "utilization review agent" but uses the term as the primary regulated entity — the party that makes adverse determinations regarding medical necessity and uses automated decision systems for utilization review.36 O.S. § 6550(1) that health care services provided or proposed to be provided to a patient are not medically necessary or appropriate, or are experimental or investigational;
(2) "AlgorithmAlgorithm"Algorithm" means a computerized procedure consisting of a set of steps used to accomplish a determined task;36 O.S. § 6550(2)" means a computerized procedure consisting of a set of steps used to accomplish a determined task;
(3) "Artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means any machine learning-based system that, for any explicit or implicit objective, infers from the inputs the system receives how to generate outputs, including content, decisions, predictions, and recommendations, that can influence physical or virtual environments;36 O.S. § 6550(3)" means any machine learning-based system that, for any explicit or implicit objective, infers from the inputs the system receives how to generate outputs, including content, decisions, predictions, and recommendations, that can influence physical or virtual environments;
(4) "Automated decision systemAutomated decision system"Automated decision system" means an algorithm, including an algorithm incorporating an artificial intelligence system, that uses data-based analytics to make, suggest, or recommend certain determinations, decisions, judgments, or conclusions;36 O.S. § 6550(4)" means an algorithmAlgorithm"Algorithm" means a computerized procedure consisting of a set of steps used to accomplish a determined task;36 O.S. § 6550(2), including an algorithmAlgorithm"Algorithm" means a computerized procedure consisting of a set of steps used to accomplish a determined task;36 O.S. § 6550(2) incorporating an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means any machine learning-based system that, for any explicit or implicit objective, infers from the inputs the system receives how to generate outputs, including content, decisions, predictions, and recommendations, that can influence physical or virtual environments;36 O.S. § 6550(3), that uses data-based analytics to make, suggest, or recommend certain determinations, decisions, judgments, or conclusions;
(5) "Qualified human professionalQualified human professional"Qualified human professional" means an individual with the training, education and certification required to legally make medical decisions.36 O.S. § 6550(5)" means an individual with the training, education and certification required to legally make medical decisions.
This section establishes the defined terms used throughout the act. Key definitions include adverse determination (a utilization review agent's finding that care is not medically necessary, appropriate, or is experimental), automated decision system (an algorithm, including AI-incorporating algorithms, that uses data-based analytics to make or recommend determinations), and qualified human professional (an individual with the training, education, and certification required to legally make medical decisions). The definitions are broadly drawn — the AI system definition tracks the EU AI Act's general formulation.
(A) 1 Any adverse determinationAdverse determination"Adverse determination" means a determination by a utilization review agent that health care services provided or proposed to be provided to a patient are not medically necessary or appropriate, or are experimental or investigational;36 O.S. § 6550(1) made by an algorithmAlgorithm"Algorithm" means a computerized procedure consisting of a set of steps used to accomplish a determined task;36 O.S. § 6550(2), artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means any machine learning-based system that, for any explicit or implicit objective, infers from the inputs the system receives how to generate outputs, including content, decisions, predictions, and recommendations, that can influence physical or virtual environments;36 O.S. § 6550(3), or automated decision systemAutomated decision system"Automated decision system" means an algorithm, including an algorithm incorporating an artificial intelligence system, that uses data-based analytics to make, suggest, or recommend certain determinations, decisions, judgments, or conclusions;36 O.S. § 6550(4) shall be reviewed by a qualified human professionalQualified human professional"Qualified human professional" means an individual with the training, education and certification required to legally make medical decisions.36 O.S. § 6550(5) before being finalized.
(B) 2 The Insurance Commissioner may audit and inspect at any time a utilization review agentUtilization review agentThe bill does not define "utilization review agent" but uses the term as the primary regulated entity — the party that makes adverse determinations regarding medical necessity and uses automated decision systems for utilization review.36 O.S. § 6550(1)'s use of an automated decision systemAutomated decision system"Automated decision system" means an algorithm, including an algorithm incorporating an artificial intelligence system, that uses data-based analytics to make, suggest, or recommend certain determinations, decisions, judgments, or conclusions;36 O.S. § 6550(4) for utilization review.
(C) This section does not prohibit the use of an algorithmAlgorithm"Algorithm" means a computerized procedure consisting of a set of steps used to accomplish a determined task;36 O.S. § 6550(2), artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means any machine learning-based system that, for any explicit or implicit objective, infers from the inputs the system receives how to generate outputs, including content, decisions, predictions, and recommendations, that can influence physical or virtual environments;36 O.S. § 6550(3), or automated decision systemAutomated decision system"Automated decision system" means an algorithm, including an algorithm incorporating an artificial intelligence system, that uses data-based analytics to make, suggest, or recommend certain determinations, decisions, judgments, or conclusions;36 O.S. § 6550(4) for administrative support or fraud-detection functions.
This section contains the bill's core operative prohibition: any adverse determination made by an algorithm, AI system, or automated decision system must be reviewed by a qualified human professional before being finalized. This is a mandatory human-in-the-loop requirement that prevents fully automated coverage denials. The Insurance Commissioner is granted standing authority to audit and inspect a utilization review agent's use of automated decision systems at any time, creating a regulatory enforcement mechanism without requiring a complaint trigger.
Subsection C provides an important safe harbor: the bill does not prohibit the use of AI or automated systems for administrative support or fraud-detection functions — only for adverse determinations affecting patient coverage.
(1)–(4) 3 Notice of an adverse determinationAdverse determination"Adverse determination" means a determination by a utilization review agent that health care services provided or proposed to be provided to a patient are not medically necessary or appropriate, or are experimental or investigational;36 O.S. § 6550(1) must include: 1. The principal reasons for the adverse determinationAdverse determination"Adverse determination" means a determination by a utilization review agent that health care services provided or proposed to be provided to a patient are not medically necessary or appropriate, or are experimental or investigational;36 O.S. § 6550(1); 2. The clinical basis for the adverse determinationAdverse determination"Adverse determination" means a determination by a utilization review agent that health care services provided or proposed to be provided to a patient are not medically necessary or appropriate, or are experimental or investigational;36 O.S. § 6550(1); 3. A description of and the source of the screening criteria and review procedures used as guidelines in making the adverse determinationAdverse determination"Adverse determination" means a determination by a utilization review agent that health care services provided or proposed to be provided to a patient are not medically necessary or appropriate, or are experimental or investigational;36 O.S. § 6550(1); and 4. A description of the procedure for the complaint and appeal process, including notice to the enrollee of the enrollee's right to appeal an adverse determinationAdverse determination"Adverse determination" means a determination by a utilization review agent that health care services provided or proposed to be provided to a patient are not medically necessary or appropriate, or are experimental or investigational;36 O.S. § 6550(1) to an independent review organization and of the procedures to obtain that review.
This section mandates that notice of any adverse determination include specific categories of information: the principal reasons for the determination, its clinical basis, a description and source of the screening criteria and review procedures used, and a description of the complaint and appeal process — including the enrollee's right to appeal to an independent review organization. This operates as both a transparency obligation (the enrollee learns why they were denied) and a procedural due process obligation (the enrollee learns how to challenge the denial).
This act shall become effective November 1, 2026.
Sets the effective date of the act as November 1, 2026.