(1) "Adverse benefit determinationAdverse benefit determination"Adverse benefit determination" means a decision not to authorize a healthcare service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. A decision by a utilization-review agent to authorize a healthcare service in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute an adverse benefit determination if the review agent and healthcare provider are in agreement regarding the decision. Adverse benefit determinations include: (i) "Administrative adverse benefit determinations" means any adverse benefit determination that does not require the use of medical judgment or clinical criteria such as a determination of an individual's eligibility to participate in coverage, a determination that a benefit is not a covered benefit, or any rescission of coverage; and (ii) "Non-administrative adverse benefit determinations" means any adverse benefit determination that requires or involves the use of medical judgement or clinical criteria to determine whether the service being reviewed is medically necessary and/or appropriate. This includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug because that drug is not on the healthcare entity's formulary.R.I. Gen. Laws § 27-83-2(1)" means a decision not to authorize a healthcare service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. A decision by a utilization-review agent to authorize a healthcare service in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute an adverse benefit determinationAdverse benefit determination"Adverse benefit determination" means a decision not to authorize a healthcare service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. A decision by a utilization-review agent to authorize a healthcare service in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute an adverse benefit determination if the review agent and healthcare provider are in agreement regarding the decision. Adverse benefit determinations include: (i) "Administrative adverse benefit determinations" means any adverse benefit determination that does not require the use of medical judgment or clinical criteria such as a determination of an individual's eligibility to participate in coverage, a determination that a benefit is not a covered benefit, or any rescission of coverage; and (ii) "Non-administrative adverse benefit determinations" means any adverse benefit determination that requires or involves the use of medical judgement or clinical criteria to determine whether the service being reviewed is medically necessary and/or appropriate. This includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug because that drug is not on the healthcare entity's formulary.R.I. Gen. Laws § 27-83-2(1) if the review agent and healthcare provider are in agreement regarding the decision. Adverse benefit determinationsAdverse benefit determination"Adverse benefit determination" means a decision not to authorize a healthcare service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. A decision by a utilization-review agent to authorize a healthcare service in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute an adverse benefit determination if the review agent and healthcare provider are in agreement regarding the decision. Adverse benefit determinations include: (i) "Administrative adverse benefit determinations" means any adverse benefit determination that does not require the use of medical judgment or clinical criteria such as a determination of an individual's eligibility to participate in coverage, a determination that a benefit is not a covered benefit, or any rescission of coverage; and (ii) "Non-administrative adverse benefit determinations" means any adverse benefit determination that requires or involves the use of medical judgement or clinical criteria to determine whether the service being reviewed is medically necessary and/or appropriate. This includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug because that drug is not on the healthcare entity's formulary.R.I. Gen. Laws § 27-83-2(1) include: (i) "Administrative adverse benefit determinationsAdverse benefit determination"Adverse benefit determination" means a decision not to authorize a healthcare service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. A decision by a utilization-review agent to authorize a healthcare service in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute an adverse benefit determination if the review agent and healthcare provider are in agreement regarding the decision. Adverse benefit determinations include: (i) "Administrative adverse benefit determinations" means any adverse benefit determination that does not require the use of medical judgment or clinical criteria such as a determination of an individual's eligibility to participate in coverage, a determination that a benefit is not a covered benefit, or any rescission of coverage; and (ii) "Non-administrative adverse benefit determinations" means any adverse benefit determination that requires or involves the use of medical judgement or clinical criteria to determine whether the service being reviewed is medically necessary and/or appropriate. This includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug because that drug is not on the healthcare entity's formulary.R.I. Gen. Laws § 27-83-2(1)" means any adverse benefit determinationAdverse benefit determination"Adverse benefit determination" means a decision not to authorize a healthcare service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. A decision by a utilization-review agent to authorize a healthcare service in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute an adverse benefit determination if the review agent and healthcare provider are in agreement regarding the decision. Adverse benefit determinations include: (i) "Administrative adverse benefit determinations" means any adverse benefit determination that does not require the use of medical judgment or clinical criteria such as a determination of an individual's eligibility to participate in coverage, a determination that a benefit is not a covered benefit, or any rescission of coverage; and (ii) "Non-administrative adverse benefit determinations" means any adverse benefit determination that requires or involves the use of medical judgement or clinical criteria to determine whether the service being reviewed is medically necessary and/or appropriate. This includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug because that drug is not on the healthcare entity's formulary.R.I. Gen. Laws § 27-83-2(1) that does not require the use of medical judgment or clinical criteria such as a determination of an individual's eligibility to participate in coverage, a determination that a benefit is not a covered benefit, or any rescission of coverage; and (ii) "Non-administrative adverse benefit determinationsAdverse benefit determination"Adverse benefit determination" means a decision not to authorize a healthcare service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. A decision by a utilization-review agent to authorize a healthcare service in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute an adverse benefit determination if the review agent and healthcare provider are in agreement regarding the decision. Adverse benefit determinations include: (i) "Administrative adverse benefit determinations" means any adverse benefit determination that does not require the use of medical judgment or clinical criteria such as a determination of an individual's eligibility to participate in coverage, a determination that a benefit is not a covered benefit, or any rescission of coverage; and (ii) "Non-administrative adverse benefit determinations" means any adverse benefit determination that requires or involves the use of medical judgement or clinical criteria to determine whether the service being reviewed is medically necessary and/or appropriate. This includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug because that drug is not on the healthcare entity's formulary.R.I. Gen. Laws § 27-83-2(1)" means any adverse benefit determinationAdverse benefit determination"Adverse benefit determination" means a decision not to authorize a healthcare service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. A decision by a utilization-review agent to authorize a healthcare service in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute an adverse benefit determination if the review agent and healthcare provider are in agreement regarding the decision. Adverse benefit determinations include: (i) "Administrative adverse benefit determinations" means any adverse benefit determination that does not require the use of medical judgment or clinical criteria such as a determination of an individual's eligibility to participate in coverage, a determination that a benefit is not a covered benefit, or any rescission of coverage; and (ii) "Non-administrative adverse benefit determinations" means any adverse benefit determination that requires or involves the use of medical judgement or clinical criteria to determine whether the service being reviewed is medically necessary and/or appropriate. This includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug because that drug is not on the healthcare entity's formulary.R.I. Gen. Laws § 27-83-2(1) that requires or involves the use of medical judgement or clinical criteria to determine whether the service being reviewed is medically necessary and/or appropriate. This includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug because that drug is not on the healthcare entity's formulary.

(2) "Artificial intelligenceArtificial intelligence"Artificial intelligence" means a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. Artificial intelligence systems use machine and human-based inputs to: (i) Perceive real and virtual environments; (ii) Abstract such perceptions into models through analysis in an automated manner; and (iii) Use model inference to formulate options for information or action.R.I. Gen. Laws § 27-83-2(2)" means a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. Artificial intelligenceArtificial intelligence"Artificial intelligence" means a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. Artificial intelligence systems use machine and human-based inputs to: (i) Perceive real and virtual environments; (ii) Abstract such perceptions into models through analysis in an automated manner; and (iii) Use model inference to formulate options for information or action.R.I. Gen. Laws § 27-83-2(2) systems use machine and human-based inputs to: (i) Perceive real and virtual environments; (ii) Abstract such perceptions into models through analysis in an automated manner; and (iii) Use model inference to formulate options for information or action.

(3) "EnrolleeEnrollee"Enrollee" means an individual who has health insurance coverage through an insurer.R.I. Gen. Laws § 27-83-2(3)" means an individual who has health insurance coverage through an insurerInsurer"Insurer" means an insurance company licensed, or required to be licensed, by the State of Rhode Island or other entity subject to the jurisdiction of the commissioner or the jurisdiction of the department of business regulation pursuant to chapter 62 of title 42, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services.R.I. Gen. Laws § 27-83-2(4).

(4) "InsurerInsurer"Insurer" means an insurance company licensed, or required to be licensed, by the State of Rhode Island or other entity subject to the jurisdiction of the commissioner or the jurisdiction of the department of business regulation pursuant to chapter 62 of title 42, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services.R.I. Gen. Laws § 27-83-2(4)" means an insurance company licensed, or required to be licensed, by the State of Rhode Island or other entity subject to the jurisdiction of the commissioner or the jurisdiction of the department of business regulation pursuant to chapter 62 of title 42, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services.

(5) "Medically necessary careMedically necessary care"Medically necessary care" means a medical, surgical, or other service required for the prevention, diagnosis, cure, or treatment of a health-related condition including any such services that are necessary to prevent or slow a decremental change in either medical or mental health status.R.I. Gen. Laws § 27-83-2(5)" means a medical, surgical, or other service required for the prevention, diagnosis, cure, or treatment of a health-related condition including any such services that are necessary to prevent or slow a decremental change in either medical or mental health status.

(a)(1) 1 The office of the health insurance commissioner (OHIC) in collaboration with the department of business regulation (DBR) shall require insurersInsurer"Insurer" means an insurance company licensed, or required to be licensed, by the State of Rhode Island or other entity subject to the jurisdiction of the commissioner or the jurisdiction of the department of business regulation pursuant to chapter 62 of title 42, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services.R.I. Gen. Laws § 27-83-2(4) subject to this chapter to disclose how they use artificial intelligenceArtificial intelligence"Artificial intelligence" means a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. Artificial intelligence systems use machine and human-based inputs to: (i) Perceive real and virtual environments; (ii) Abstract such perceptions into models through analysis in an automated manner; and (iii) Use model inference to formulate options for information or action.R.I. Gen. Laws § 27-83-2(2) to manage healthcare claims and coverage including, but not limited to, the types of artificial intelligenceArtificial intelligence"Artificial intelligence" means a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. Artificial intelligence systems use machine and human-based inputs to: (i) Perceive real and virtual environments; (ii) Abstract such perceptions into models through analysis in an automated manner; and (iii) Use model inference to formulate options for information or action.R.I. Gen. Laws § 27-83-2(2) models used, the role of artificial intelligenceArtificial intelligence"Artificial intelligence" means a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. Artificial intelligence systems use machine and human-based inputs to: (i) Perceive real and virtual environments; (ii) Abstract such perceptions into models through analysis in an automated manner; and (iii) Use model inference to formulate options for information or action.R.I. Gen. Laws § 27-83-2(2) in the decision-making process, training datasets, performance metrics, governance and risk management policies, and the decisions on healthcare claims and coverage where artificial intelligenceArtificial intelligence"Artificial intelligence" means a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. Artificial intelligence systems use machine and human-based inputs to: (i) Perceive real and virtual environments; (ii) Abstract such perceptions into models through analysis in an automated manner; and (iii) Use model inference to formulate options for information or action.R.I. Gen. Laws § 27-83-2(2) made, or was a substantial factor in making, the decisions.

(a)(2) 2 InsurersInsurer"Insurer" means an insurance company licensed, or required to be licensed, by the State of Rhode Island or other entity subject to the jurisdiction of the commissioner or the jurisdiction of the department of business regulation pursuant to chapter 62 of title 42, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services.R.I. Gen. Laws § 27-83-2(4) shall submit to the office of the health insurance commissioner and the department of business regulation, upon request, all information, including documents and software, that permits enforcement of this chapter.

(a)(3) 3 InsurersInsurer"Insurer" means an insurance company licensed, or required to be licensed, by the State of Rhode Island or other entity subject to the jurisdiction of the commissioner or the jurisdiction of the department of business regulation pursuant to chapter 62 of title 42, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services.R.I. Gen. Laws § 27-83-2(4) shall maintain documentation of artificial intelligenceArtificial intelligence"Artificial intelligence" means a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. Artificial intelligence systems use machine and human-based inputs to: (i) Perceive real and virtual environments; (ii) Abstract such perceptions into models through analysis in an automated manner; and (iii) Use model inference to formulate options for information or action.R.I. Gen. Laws § 27-83-2(2) decisions for at least five (5) years including adverse benefit determinationsAdverse benefit determination"Adverse benefit determination" means a decision not to authorize a healthcare service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. A decision by a utilization-review agent to authorize a healthcare service in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute an adverse benefit determination if the review agent and healthcare provider are in agreement regarding the decision. Adverse benefit determinations include: (i) "Administrative adverse benefit determinations" means any adverse benefit determination that does not require the use of medical judgment or clinical criteria such as a determination of an individual's eligibility to participate in coverage, a determination that a benefit is not a covered benefit, or any rescission of coverage; and (ii) "Non-administrative adverse benefit determinations" means any adverse benefit determination that requires or involves the use of medical judgement or clinical criteria to determine whether the service being reviewed is medically necessary and/or appropriate. This includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug because that drug is not on the healthcare entity's formulary.R.I. Gen. Laws § 27-83-2(1) where artificial intelligenceArtificial intelligence"Artificial intelligence" means a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. Artificial intelligence systems use machine and human-based inputs to: (i) Perceive real and virtual environments; (ii) Abstract such perceptions into models through analysis in an automated manner; and (iii) Use model inference to formulate options for information or action.R.I. Gen. Laws § 27-83-2(2) made, or was a substantial factor in making, the adverse benefit determinationAdverse benefit determination"Adverse benefit determination" means a decision not to authorize a healthcare service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. A decision by a utilization-review agent to authorize a healthcare service in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute an adverse benefit determination if the review agent and healthcare provider are in agreement regarding the decision. Adverse benefit determinations include: (i) "Administrative adverse benefit determinations" means any adverse benefit determination that does not require the use of medical judgment or clinical criteria such as a determination of an individual's eligibility to participate in coverage, a determination that a benefit is not a covered benefit, or any rescission of coverage; and (ii) "Non-administrative adverse benefit determinations" means any adverse benefit determination that requires or involves the use of medical judgement or clinical criteria to determine whether the service being reviewed is medically necessary and/or appropriate. This includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug because that drug is not on the healthcare entity's formulary.R.I. Gen. Laws § 27-83-2(1).

(b)(1)–(2) 4 DBR/OHIC shall provide an annual report to the governor, the senate president and the speaker of the house on the use of artificial intelligenceArtificial intelligence"Artificial intelligence" means a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. Artificial intelligence systems use machine and human-based inputs to: (i) Perceive real and virtual environments; (ii) Abstract such perceptions into models through analysis in an automated manner; and (iii) Use model inference to formulate options for information or action.R.I. Gen. Laws § 27-83-2(2) by health insurersInsurer"Insurer" means an insurance company licensed, or required to be licensed, by the State of Rhode Island or other entity subject to the jurisdiction of the commissioner or the jurisdiction of the department of business regulation pursuant to chapter 62 of title 42, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services.R.I. Gen. Laws § 27-83-2(4). The annual report shall state how health insurersInsurer"Insurer" means an insurance company licensed, or required to be licensed, by the State of Rhode Island or other entity subject to the jurisdiction of the commissioner or the jurisdiction of the department of business regulation pursuant to chapter 62 of title 42, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services.R.I. Gen. Laws § 27-83-2(4) use artificial intelligenceArtificial intelligence"Artificial intelligence" means a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. Artificial intelligence systems use machine and human-based inputs to: (i) Perceive real and virtual environments; (ii) Abstract such perceptions into models through analysis in an automated manner; and (iii) Use model inference to formulate options for information or action.R.I. Gen. Laws § 27-83-2(2) to manage claims and coverage. The report shall state for each insurerInsurer"Insurer" means an insurance company licensed, or required to be licensed, by the State of Rhode Island or other entity subject to the jurisdiction of the commissioner or the jurisdiction of the department of business regulation pursuant to chapter 62 of title 42, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services.R.I. Gen. Laws § 27-83-2(4): (i) The types of artificial intelligenceArtificial intelligence"Artificial intelligence" means a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. Artificial intelligence systems use machine and human-based inputs to: (i) Perceive real and virtual environments; (ii) Abstract such perceptions into models through analysis in an automated manner; and (iii) Use model inference to formulate options for information or action.R.I. Gen. Laws § 27-83-2(2) models used; (ii) The role of artificial intelligenceArtificial intelligence"Artificial intelligence" means a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. Artificial intelligence systems use machine and human-based inputs to: (i) Perceive real and virtual environments; (ii) Abstract such perceptions into models through analysis in an automated manner; and (iii) Use model inference to formulate options for information or action.R.I. Gen. Laws § 27-83-2(2) in the decision-making process to approve or deny healthcare claims or coverage whenever artificial intelligenceArtificial intelligence"Artificial intelligence" means a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. Artificial intelligence systems use machine and human-based inputs to: (i) Perceive real and virtual environments; (ii) Abstract such perceptions into models through analysis in an automated manner; and (iii) Use model inference to formulate options for information or action.R.I. Gen. Laws § 27-83-2(2) is used to make, or is a substantial factor in making, a decision on healthcare claims or coverage; (iii) Information regarding training, testing, and risk management including data governance measures used to cover the training data sets and the measures used to examine the suitability of data sources, possible biases and appropriate mitigation; and (iv) Performance metrics including, number of claims, percentage of claims accepted and denied; the average time claim reviewers and medical professional reviewers spend on each claim and on denials of claims; percentage of claims appealed and percentage of denials reversed.

(b)(3) By June 30, 2026, DBR/OHIC shall promulgate rules and regulations setting forth requirements for health insurersInsurer"Insurer" means an insurance company licensed, or required to be licensed, by the State of Rhode Island or other entity subject to the jurisdiction of the commissioner or the jurisdiction of the department of business regulation pursuant to chapter 62 of title 42, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including, without limitation: a for-profit or nonprofit hospital, medical or dental service corporation or plan, a health maintenance organization, a health insurance company, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services.R.I. Gen. Laws § 27-83-2(4) covered under this chapter to comply with the reporting requirements of this chapter.

5 Any adverse benefit determinationAdverse benefit determination"Adverse benefit determination" means a decision not to authorize a healthcare service, including a denial, reduction, or termination of, or a failure to provide or make a payment, in whole or in part, for a benefit. A decision by a utilization-review agent to authorize a healthcare service in an alternative setting, a modified extension of stay, or an alternative treatment shall not constitute an adverse benefit determination if the review agent and healthcare provider are in agreement regarding the decision. Adverse benefit determinations include: (i) "Administrative adverse benefit determinations" means any adverse benefit determination that does not require the use of medical judgment or clinical criteria such as a determination of an individual's eligibility to participate in coverage, a determination that a benefit is not a covered benefit, or any rescission of coverage; and (ii) "Non-administrative adverse benefit determinations" means any adverse benefit determination that requires or involves the use of medical judgement or clinical criteria to determine whether the service being reviewed is medically necessary and/or appropriate. This includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug because that drug is not on the healthcare entity's formulary.R.I. Gen. Laws § 27-83-2(1) made by an artificial intelligenceArtificial intelligence"Artificial intelligence" means a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments. Artificial intelligence systems use machine and human-based inputs to: (i) Perceive real and virtual environments; (ii) Abstract such perceptions into models through analysis in an automated manner; and (iii) Use model inference to formulate options for information or action.R.I. Gen. Laws § 27-83-2(2) system regarding medically necessary careMedically necessary care"Medically necessary care" means a medical, surgical, or other service required for the prevention, diagnosis, cure, or treatment of a health-related condition including any such services that are necessary to prevent or slow a decremental change in either medical or mental health status.R.I. Gen. Laws § 27-83-2(5) must be reviewed and approved by a qualified healthcare professional before being finalized, with documentation of their rationale included in the enrolleeEnrollee"Enrollee" means an individual who has health insurance coverage through an insurer.R.I. Gen. Laws § 27-83-2(3)'s case record.

If any provision of this chapter is found unconstitutional, preempted, or otherwise invalid, that provision shall be severed, and such decision shall not affect the validity of the remaining provisions of this chapter.