(a)(1)–(2) 1 A health planHealth planA health plan, as defined in section 9418 of this title18 V.S.A. § 9423(a), as defined in section 9418 of this title, that uses an artificial intelligence, algorithm, or other software tool for the purpose of utilization review, or that contracts with or otherwise works through an entity that uses an artificial intelligence, algorithm, or other software tool for the purpose of utilization review, shall ensure all of the following: (1) The artificial intelligence, algorithm, or other software tool bases its determination on the following information, as applicable: (A) an insured's medical or other clinical history; (B) the specific clinical circumstances as presented by the requesting health care provider; and (C) other relevant clinical information contained in the insured's medical or other clinical record. (2) The artificial intelligence, algorithm, or other software tool does not base its determination solely on a group dataset.

(a)(3)–(4) 2 The artificial intelligence, algorithm, or other software tool is fairly applied, including in accordance with any applicable regulations and guidance issued by the U.S. Department of Health and Human Services. (4) The artificial intelligence, algorithm, or other software tool is configured and applied in a standard, consistent manner for all health plansHealth planA health plan, as defined in section 9418 of this title18 V.S.A. § 9423(a) and insureds so that the resulting decisions are the same for all patients with similar clinical presentation and considerations.

(a)(5) 3 The artificial intelligence, algorithm, or other software tool is open to inspection for audit or compliance reviews by the Department of Financial Regulation and by other State agencies and departments pursuant to applicable State and federal law.

(a)(6) 4 Disclosures pertaining to the use of the artificial intelligence, algorithm, or other software tool in the utilization review process and the nature and degree of human review and oversight are contained in the health planHealth planA health plan, as defined in section 9418 of this title18 V.S.A. § 9423(a)'s written policies and procedures to the extent required by the Department of Financial Regulation.

(a)(7) 5 The artificial intelligence, algorithm, or other software tool's performance, use, and outcomes are reviewed and revised at least quarterly to maximize accuracy and reliability.

(a)(8) 6 The artificial intelligence, algorithm, or other software tool does not directly or indirectly cause harm to the insured.

(b) 7 The artificial intelligence, algorithm, or other software tool utilized by a health planHealth planA health plan, as defined in section 9418 of this title18 V.S.A. § 9423(a) shall not deny, delay, or modify a determination of whether to authorize the coverage of health care services. An adverse coverage determination shall be made only by a licensed human health care provider who is competent to evaluate the specific clinical issues involved in the health care services requested by a treating health care provider by reviewing and considering the requesting provider's recommendation; the insured's medical or other clinical history, as appropriate; and the specific clinical circumstances.