(1) "Adverse benefit determinationAdverse benefit determination"Adverse benefit determination" means a decision not to authorize coverage for 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 ordering provider are in agreement regarding the decision. "Adverse benefit determination" includes: (i) "Administrative adverse benefit determination," meaning 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 determination," meaning 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 determination includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug due to the fact that the drug is not on the insurer's formulary.R.I. Gen. Laws § 27-84-2(1)" means a decision not to authorize coverage for 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 coverage for 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 ordering provider are in agreement regarding the decision. "Adverse benefit determination" includes: (i) "Administrative adverse benefit determination," meaning 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 determination," meaning 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 determination includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug due to the fact that the drug is not on the insurer's formulary.R.I. Gen. Laws § 27-84-2(1) if the review agent and ordering providerProvider"Provider" means a physician, hospital, professional provider, pharmacy, laboratory, dental, medical, or behavioral health provider or other state-licensed or other state-recognized provider of health care or behavioral health services or supplies.R.I. Gen. Laws § 27-84-2(6) are in agreement regarding the decision. "Adverse benefit determinationAdverse benefit determination"Adverse benefit determination" means a decision not to authorize coverage for 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 ordering provider are in agreement regarding the decision. "Adverse benefit determination" includes: (i) "Administrative adverse benefit determination," meaning 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 determination," meaning 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 determination includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug due to the fact that the drug is not on the insurer's formulary.R.I. Gen. Laws § 27-84-2(1)" includes: (i) "Administrative adverse benefit determinationAdverse benefit determination"Adverse benefit determination" means a decision not to authorize coverage for 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 ordering provider are in agreement regarding the decision. "Adverse benefit determination" includes: (i) "Administrative adverse benefit determination," meaning 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 determination," meaning 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 determination includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug due to the fact that the drug is not on the insurer's formulary.R.I. Gen. Laws § 27-84-2(1)," meaning any adverse benefit determinationAdverse benefit determination"Adverse benefit determination" means a decision not to authorize coverage for 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 ordering provider are in agreement regarding the decision. "Adverse benefit determination" includes: (i) "Administrative adverse benefit determination," meaning 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 determination," meaning 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 determination includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug due to the fact that the drug is not on the insurer's formulary.R.I. Gen. Laws § 27-84-2(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 determinationAdverse benefit determination"Adverse benefit determination" means a decision not to authorize coverage for 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 ordering provider are in agreement regarding the decision. "Adverse benefit determination" includes: (i) "Administrative adverse benefit determination," meaning 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 determination," meaning 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 determination includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug due to the fact that the drug is not on the insurer's formulary.R.I. Gen. Laws § 27-84-2(1)," meaning any adverse benefit determinationAdverse benefit determination"Adverse benefit determination" means a decision not to authorize coverage for 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 ordering provider are in agreement regarding the decision. "Adverse benefit determination" includes: (i) "Administrative adverse benefit determination," meaning 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 determination," meaning 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 determination includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug due to the fact that the drug is not on the insurer's formulary.R.I. Gen. Laws § 27-84-2(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 determination includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug due to the fact that the drug is not on the 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, 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, a healthcare entity as defined in 27-18.9-2, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services. Insurer includes any agent or contracted entity acting on behalf of the insurer in the administration, review, or determination of healthcare claims or coverage.R.I. Gen. Laws § 27-84-2(4)'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 § 27-84-2(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 § 27-84-2(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 § 27-84-2(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, 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, a healthcare entity as defined in 27-18.9-2, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services. Insurer includes any agent or contracted entity acting on behalf of the insurer in the administration, review, or determination of healthcare claims or coverage.R.I. Gen. Laws § 27-84-2(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, 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, a healthcare entity as defined in 27-18.9-2, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services. Insurer includes any agent or contracted entity acting on behalf of the insurer in the administration, review, or determination of healthcare claims or coverage.R.I. Gen. Laws § 27-84-2(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, 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, a healthcare entity as defined in 27-18.9-2, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services. 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, 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, a healthcare entity as defined in 27-18.9-2, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services. Insurer includes any agent or contracted entity acting on behalf of the insurer in the administration, review, or determination of healthcare claims or coverage.R.I. Gen. Laws § 27-84-2(4) includes any agent or contracted entity acting on behalf of the 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, 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, a healthcare entity as defined in 27-18.9-2, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services. Insurer includes any agent or contracted entity acting on behalf of the insurer in the administration, review, or determination of healthcare claims or coverage.R.I. Gen. Laws § 27-84-2(4) in the administration, review, or determination of healthcare claims or coverage.

(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 § 27-84-2(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.

(6) "ProviderProvider"Provider" means a physician, hospital, professional provider, pharmacy, laboratory, dental, medical, or behavioral health provider or other state-licensed or other state-recognized provider of health care or behavioral health services or supplies.R.I. Gen. Laws § 27-84-2(6)" means a physician, hospital, professional providerProvider"Provider" means a physician, hospital, professional provider, pharmacy, laboratory, dental, medical, or behavioral health provider or other state-licensed or other state-recognized provider of health care or behavioral health services or supplies.R.I. Gen. Laws § 27-84-2(6), pharmacy, laboratory, dental, medical, or behavioral health providerProvider"Provider" means a physician, hospital, professional provider, pharmacy, laboratory, dental, medical, or behavioral health provider or other state-licensed or other state-recognized provider of health care or behavioral health services or supplies.R.I. Gen. Laws § 27-84-2(6) or other state-licensed or other state-recognized provider of health care or behavioral health services or supplies.

(a)(1) 1 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, 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, a healthcare entity as defined in 27-18.9-2, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services. Insurer includes any agent or contracted entity acting on behalf of the insurer in the administration, review, or determination of healthcare claims or coverage.R.I. Gen. Laws § 27-84-2(4) subject to this chapter shall disclose to the office of the health insurance commissioner ("OHIC") and the department of business regulation ("DBR") 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 § 27-84-2(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 § 27-84-2(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 § 27-84-2(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 § 27-84-2(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, 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, a healthcare entity as defined in 27-18.9-2, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services. Insurer includes any agent or contracted entity acting on behalf of the insurer in the administration, review, or determination of healthcare claims or coverage.R.I. Gen. Laws § 27-84-2(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, 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, a healthcare entity as defined in 27-18.9-2, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services. Insurer includes any agent or contracted entity acting on behalf of the insurer in the administration, review, or determination of healthcare claims or coverage.R.I. Gen. Laws § 27-84-2(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 § 27-84-2(2) decisions for at least five (5) years including adverse benefit determinationsAdverse benefit determination"Adverse benefit determination" means a decision not to authorize coverage for 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 ordering provider are in agreement regarding the decision. "Adverse benefit determination" includes: (i) "Administrative adverse benefit determination," meaning 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 determination," meaning 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 determination includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug due to the fact that the drug is not on the insurer's formulary.R.I. Gen. Laws § 27-84-2(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 § 27-84-2(2) made, or was a substantial factor in making, the adverse benefit determinationAdverse benefit determination"Adverse benefit determination" means a decision not to authorize coverage for 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 ordering provider are in agreement regarding the decision. "Adverse benefit determination" includes: (i) "Administrative adverse benefit determination," meaning 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 determination," meaning 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 determination includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug due to the fact that the drug is not on the insurer's formulary.R.I. Gen. Laws § 27-84-2(1).

(b)(1) DBR/OHIC shall provide an initial 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 § 27-84-2(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, 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, a healthcare entity as defined in 27-18.9-2, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services. Insurer includes any agent or contracted entity acting on behalf of the insurer in the administration, review, or determination of healthcare claims or coverage.R.I. Gen. Laws § 27-84-2(4) within eighteen (18) months of the effective date of this chapter and annually thereafter.

(b)(2) 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, 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, a healthcare entity as defined in 27-18.9-2, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services. Insurer includes any agent or contracted entity acting on behalf of the insurer in the administration, review, or determination of healthcare claims or coverage.R.I. Gen. Laws § 27-84-2(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 § 27-84-2(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, 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, a healthcare entity as defined in 27-18.9-2, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services. Insurer includes any agent or contracted entity acting on behalf of the insurer in the administration, review, or determination of healthcare claims or coverage.R.I. Gen. Laws § 27-84-2(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 § 27-84-2(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 § 27-84-2(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 § 27-84-2(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.

(a) 4 Any non-administrative adverse benefit determinationAdverse benefit determination"Adverse benefit determination" means a decision not to authorize coverage for 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 ordering provider are in agreement regarding the decision. "Adverse benefit determination" includes: (i) "Administrative adverse benefit determination," meaning 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 determination," meaning 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 determination includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug due to the fact that the drug is not on the insurer's formulary.R.I. Gen. Laws § 27-84-2(1) where 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 § 27-84-2(2) system made, or was a substantial factor in making, that determination 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 § 27-84-2(5) shall be reviewed and approved by a providerProvider"Provider" means a physician, hospital, professional provider, pharmacy, laboratory, dental, medical, or behavioral health provider or other state-licensed or other state-recognized provider of health care or behavioral health services or supplies.R.I. Gen. Laws § 27-84-2(6) with the same license status of the ordering professional providerProvider"Provider" means a physician, hospital, professional provider, pharmacy, laboratory, dental, medical, or behavioral health provider or other state-licensed or other state-recognized provider of health care or behavioral health services or supplies.R.I. Gen. Laws § 27-84-2(6) 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 § 27-84-2(3)'s case record. Failure to follow the requirements set forth in this subsection shall render the non-administrative adverse benefit determinationAdverse benefit determination"Adverse benefit determination" means a decision not to authorize coverage for 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 ordering provider are in agreement regarding the decision. "Adverse benefit determination" includes: (i) "Administrative adverse benefit determination," meaning 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 determination," meaning 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 determination includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug due to the fact that the drug is not on the insurer's formulary.R.I. Gen. Laws § 27-84-2(1) invalid and require reconsideration in compliance with this subsection.

(b) Appeals of non-administrative adverse benefit determinationsAdverse benefit determination"Adverse benefit determination" means a decision not to authorize coverage for 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 ordering provider are in agreement regarding the decision. "Adverse benefit determination" includes: (i) "Administrative adverse benefit determination," meaning 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 determination," meaning 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 determination includes the denial of treatments determined to be experimental or investigational, and any denial of coverage of a prescription drug due to the fact that the drug is not on the insurer's formulary.R.I. Gen. Laws § 27-84-2(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 § 27-84-2(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 § 27-84-2(5) that has been reviewed and approved by a providerProvider"Provider" means a physician, hospital, professional provider, pharmacy, laboratory, dental, medical, or behavioral health provider or other state-licensed or other state-recognized provider of health care or behavioral health services or supplies.R.I. Gen. Laws § 27-84-2(6) with the same license status of the ordering professional providerProvider"Provider" means a physician, hospital, professional provider, pharmacy, laboratory, dental, medical, or behavioral health provider or other state-licensed or other state-recognized provider of health care or behavioral health services or supplies.R.I. Gen. Laws § 27-84-2(6) shall comply with the appeals process set forth in chapter 18.9 of title 27.

(a) OHIC, in collaboration with DBR, shall promulgate rules and regulations that may be necessary to effectuate the purposes and implementation of this chapter.

(b) The total cost of complying with the requirements of this chapter and the applicable rules and regulations shall be borne by the 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, 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, a healthcare entity as defined in 27-18.9-2, or any other entity providing a plan of health insurance, accident and sickness insurance, health benefits, or healthcare services. Insurer includes any agent or contracted entity acting on behalf of the insurer in the administration, review, or determination of healthcare claims or coverage.R.I. Gen. Laws § 27-84-2(4).

27-84-6 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.

SECTION 2 This act shall take effect upon passage.