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) "Artificial intelligenceArtificial intelligence"Artificial intelligence" means a computer system, program, or set of algorithms capable of performing tasks on producing outposts that imitate intelligent human behaviors;36 O.S. § 6552(1)" means a computer system, program, or set of algorithms capable of performing tasks on producing outposts that imitate intelligent human behaviors;
"Artificial intelligence toolArtificial intelligence tool"Artificial intelligence tool" means a tool that uses an artificial intelligence or algorithm for the purpose of utilization review based in whole or in part on medical necessity;36 O.S. § 6552" means a tool that uses an artificial intelligenceArtificial intelligence"Artificial intelligence" means a computer system, program, or set of algorithms capable of performing tasks on producing outposts that imitate intelligent human behaviors;36 O.S. § 6552(1) or algorithm for the purpose of utilization reviewUtilization review"Utilization review" means a system for prospectively, concurrently, and retrospectively reviewing the allocation of hospital resources and medical services given or proposed to be given to a patient or group of patients. It does not include an insurer's normal claim review process to determine compliance with the specific terms and conditions of the insurance policy;36 O.S. § 6552(7) based in whole or in part on medical necessity;
(3) "CommissionerCommissioner"Commissioner" means the Insurance Commissioner;36 O.S. § 6552(3)" means the Insurance CommissionerCommissioner"Commissioner" means the Insurance Commissioner;36 O.S. § 6552(3);
(4) "CertificateCertificate"Certificate" means a certificate of registration granted by the Insurance Commissioner to a private review agent;36 O.S. § 6552(4)" means a certificate of registration granted by the Insurance CommissionerCommissioner"Commissioner" means the Insurance Commissioner;36 O.S. § 6552(3) to a private review agentPrivate review agent"Private review agent" means a person or entity that performs utilization review on behalf of: a. an employer in this state, or b. a third party that provides or administers hospital and medical benefits to citizens of this state, including, but not limited to: (1) a health maintenance organization issued a license pursuant to Section 6901 et seq. of this title, unless the health maintenance organization is federally regulated and licensed and has on file with the Insurance Commissioner a plan of utilization review carried out by health care professionals and providing for complaint and appellate procedures for claims, or (2) a health insurer, not-for-profit hospital service or medical plan, health insurance service organization, or preferred provider organization or other entity offering health insurance policies, contracts or benefits in this state;36 O.S. § 6552(6);
(5) "Health care providerHealth care provider"Health care provider" means any person, firm, corporation or other legal entity that is licensed, certified, or otherwise authorized by the laws of this state to provide health care services, procedures or supplies in the ordinary course of business or practice of a profession;36 O.S. § 6552(5)" means any person, firm, corporation or other legal entity that is licensed, certified, or otherwise authorized by the laws of this state to provide health care services, procedures or supplies in the ordinary course of business or practice of a profession;
(6) "Private review agentPrivate review agent"Private review agent" means a person or entity that performs utilization review on behalf of: a. an employer in this state, or b. a third party that provides or administers hospital and medical benefits to citizens of this state, including, but not limited to: (1) a health maintenance organization issued a license pursuant to Section 6901 et seq. of this title, unless the health maintenance organization is federally regulated and licensed and has on file with the Insurance Commissioner a plan of utilization review carried out by health care professionals and providing for complaint and appellate procedures for claims, or (2) a health insurer, not-for-profit hospital service or medical plan, health insurance service organization, or preferred provider organization or other entity offering health insurance policies, contracts or benefits in this state;36 O.S. § 6552(6)" means a person or entity that performs utilization reviewUtilization review"Utilization review" means a system for prospectively, concurrently, and retrospectively reviewing the allocation of hospital resources and medical services given or proposed to be given to a patient or group of patients. It does not include an insurer's normal claim review process to determine compliance with the specific terms and conditions of the insurance policy;36 O.S. § 6552(7) on behalf of: a. an employer in this state, or b. a third party that provides or administers hospital and medical benefits to citizens of this state, including, but not limited to: (1) a health maintenance organization issued a license pursuant to Section 6901 et seq. of this title, unless the health maintenance organization is federally regulated and licensed and has on file with the Insurance CommissionerCommissioner"Commissioner" means the Insurance Commissioner;36 O.S. § 6552(3) a plan of utilization reviewUtilization review"Utilization review" means a system for prospectively, concurrently, and retrospectively reviewing the allocation of hospital resources and medical services given or proposed to be given to a patient or group of patients. It does not include an insurer's normal claim review process to determine compliance with the specific terms and conditions of the insurance policy;36 O.S. § 6552(7) carried out by health care professionals and providing for complaint and appellate procedures for claims, or (2) a health insurer, not-for-profit hospital service or medical plan, health insurance service organization, or preferred provider organization or other entity offering health insurance policies, contracts or benefits in this state;
(7) "Utilization reviewUtilization review"Utilization review" means a system for prospectively, concurrently, and retrospectively reviewing the allocation of hospital resources and medical services given or proposed to be given to a patient or group of patients. It does not include an insurer's normal claim review process to determine compliance with the specific terms and conditions of the insurance policy;36 O.S. § 6552(7)" means a system for prospectively, concurrently, and retrospectively reviewing the allocation of hospital resources and medical services given or proposed to be given to a patient or group of patients. It does not include an insurer's normal claim review process to determine compliance with the specific terms and conditions of the insurance policy;
(8) "Utilization review planUtilization review plan"Utilization review plan" means a description of utilization review procedures;36 O.S. § 6552(8)" means a description of utilization reviewUtilization review"Utilization review" means a system for prospectively, concurrently, and retrospectively reviewing the allocation of hospital resources and medical services given or proposed to be given to a patient or group of patients. It does not include an insurer's normal claim review process to determine compliance with the specific terms and conditions of the insurance policy;36 O.S. § 6552(7) procedures;
(9) "Utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in Section 6475.3 of this title.36 O.S. § 6552(9)" means the same as defined in Section 6475.3 of this title.
Section 1 of the bill amends existing 36 O.S. § 6552 to add two new defined terms — artificial intelligence and artificial intelligence tool — and reorganizes the existing definitions within the Hospital and Medical Services Utilization Review Act. The AI tool definition is scoped specifically to tools used for utilization review based in whole or in part on medical necessity, which limits the bill's reach to clinical decision-support tools rather than all AI used by insurers.
The definition of 'artificial intelligence' appears to contain a typographical error ('outposts' likely intended to read 'outputs'). Practitioners should expect this to be corrected in subsequent versions or through errata.
A(1)–(2) 1 A. A utilization review organizationUtilization review organization"Utilization review organization" means the same as defined in Section 6475.3 of this title.36 O.S. § 6552(9), disability insurer, or specialized health insurer that uses an artificial intelligence toolArtificial intelligence tool"Artificial intelligence tool" means a tool that uses an artificial intelligence or algorithm for the purpose of utilization review based in whole or in part on medical necessity;36 O.S. § 6552 or contracts with or otherwise works through an entity that uses an artificial intelligence toolArtificial intelligence tool"Artificial intelligence tool" means a tool that uses an artificial intelligence or algorithm for the purpose of utilization review based in whole or in part on medical necessity;36 O.S. § 6552 shall ensure that the artificial intelligence toolArtificial intelligence tool"Artificial intelligence tool" means a tool that uses an artificial intelligence or algorithm for the purpose of utilization review based in whole or in part on medical necessity;36 O.S. § 6552: 1. Bases its determination on the following information, as applicable: a. an enrollee's medical or other clinical history, b. individual clinical circumstances as presented by the requesting provider, and c. other relevant clinical information contained in the enrollee's medical or other clinical record; 2. Does not base its determination solely on a group dataset;
A(3) 2 3. Does not supplant health care providerHealth care provider"Health care provider" means any person, firm, corporation or other legal entity that is licensed, certified, or otherwise authorized by the laws of this state to provide health care services, procedures or supplies in the ordinary course of business or practice of a profession;36 O.S. § 6552(5) decision-making;
A(4) 3 4. Does not discriminate against enrollees in violation of state and federal law;
A(5) 4 5. Does not use patient data beyond its intended and stated purpose consistent with the federal Health Insurance Portability and Accountability Act of 1996, P.L. No. 104-191, as applicable;
A(6) 5 6. Does not cause harm to the enrollee;
A(7) 6 7. Is applied in accordance with any applicable regulations and guidance issued by the federal Department of Health and Human Services;
A(8) 7 8. Is open to inspection for audit or compliance review by the Insurance CommissionerCommissioner"Commissioner" means the Insurance Commissioner;36 O.S. § 6552(3);
A(9) 8 9. Contains disclosures pertaining to the use and oversight of the artificial intelligence toolArtificial intelligence tool"Artificial intelligence tool" means a tool that uses an artificial intelligence or algorithm for the purpose of utilization review based in whole or in part on medical necessity;36 O.S. § 6552 in the written policies and procedures;
A(10) 9 10. Requires performance use and outcomes to be periodically reviewed and revised to maximize accuracy and reliability.
B 10 B. The artificial intelligence toolArtificial intelligence tool"Artificial intelligence tool" means a tool that uses an artificial intelligence or algorithm for the purpose of utilization review based in whole or in part on medical necessity;36 O.S. § 6552 shall not deny, delay, or modify health care 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 health care professional competent to evaluate the specific clinical issues involved in the health care services requested by the provider, by reviewing and considering the requesting provider's recommendation, the enrollee's medical or other clinical history, and individual circumstances.
C 11 C. Any health benefit plan in this state shall notify enrollees and insureds about the use or lack of use of artificial intelligence toolsArtificial intelligence tool"Artificial intelligence tool" means a tool that uses an artificial intelligence or algorithm for the purpose of utilization review based in whole or in part on medical necessity;36 O.S. § 6552 in the utilization reviewUtilization review"Utilization review" means a system for prospectively, concurrently, and retrospectively reviewing the allocation of hospital resources and medical services given or proposed to be given to a patient or group of patients. It does not include an insurer's normal claim review process to determine compliance with the specific terms and conditions of the insurance policy;36 O.S. § 6552(7) process on the accessible Internet website of such health benefit plan.
D 12 D. A clinical peer reviewer who participates in a utilization reviewUtilization review"Utilization review" means a system for prospectively, concurrently, and retrospectively reviewing the allocation of hospital resources and medical services given or proposed to be given to a patient or group of patients. It does not include an insurer's normal claim review process to determine compliance with the specific terms and conditions of the insurance policy;36 O.S. § 6552(7) process for a health benefit plan that initially uses artificial intelligence toolsArtificial intelligence tool"Artificial intelligence tool" means a tool that uses an artificial intelligence or algorithm for the purpose of utilization review based in whole or in part on medical necessity;36 O.S. § 6552 for a utilization reviewUtilization review"Utilization review" means a system for prospectively, concurrently, and retrospectively reviewing the allocation of hospital resources and medical services given or proposed to be given to a patient or group of patients. It does not include an insurer's normal claim review process to determine compliance with the specific terms and conditions of the insurance policy;36 O.S. § 6552(7) shall open and document the utilization review of the individual clinical records or data prior to issuing an adverse determination.
E–F E. A violation of this act by a health benefit plan or clinical peer reviewer shall be subject to one or more of the following penalties, not to exceed in aggregate Five Hundred Thousand Dollars ($500,000.00) for a health benefit plan or One Hundred Thousand Dollars ($100,000.00) for a clinical peer reviewer, in a calendar year: 1. Suspension or revocation of a license; 2. Refusal, for a period not to exceed one (1) year, to issue a new license; or 3. A fine not more than Ten Thousand Dollars ($10,000.00) for each willful violation. F. Penalties pursuant to this act shall be in addition to any other remedies or penalties that may be imposed under any other applicable state or federal law.
G G. This act shall apply to utilization reviewUtilization review"Utilization review" means a system for prospectively, concurrently, and retrospectively reviewing the allocation of hospital resources and medical services given or proposed to be given to a patient or group of patients. It does not include an insurer's normal claim review process to determine compliance with the specific terms and conditions of the insurance policy;36 O.S. § 6552(7) or utilization management functions that prospectively, concurrently, retrospectively review requests for covered health care services.
H H. The CommissionerCommissioner"Commissioner" means the Insurance Commissioner;36 O.S. § 6552(3) may promulgate rules and regulations pursuant to the provisions of this act.
Section 2 creates new Section 6567, the operative heart of the bill. Subsection A imposes ten enumerated requirements on utilization review organizations, disability insurers, and specialized health insurers that use (or contract with entities that use) AI tools. The requirements mandate individualized clinical data inputs, prohibit sole reliance on group datasets, bar the AI tool from supplanting provider decision-making, require non-discrimination, limit patient data use consistent with HIPAA, prohibit enrollee harm, require compliance with federal HHS guidance, mandate regulatory openness to inspection, require internal policy disclosures, and require periodic performance review.
Subsection B flatly prohibits the AI tool from denying, delaying, or modifying health care services based on medical necessity — reserving medical necessity determinations exclusively to licensed physicians or clinically competent health care professionals who must consider the treating provider's recommendation and the enrollee's individual clinical history. Subsection C requires health benefit plans to notify enrollees about AI tool usage on their public website. Subsection D requires clinical peer reviewers to open and document the individual clinical record before issuing an adverse determination when AI was initially used.
Subsections E–F set out enforcement penalties and savings language. Subsection G scopes the act to prospective, concurrent, and retrospective utilization review. Subsection H authorizes the Commissioner to promulgate implementing rules.
SECTION 3. This act shall become effective November 1, 2026.
Section 3 sets the effective date of the act as November 1, 2026.