(b)(1) An insurer that uses artificial intelligence to make determinations on requests for prior authorization under health benefit plans shall base determinations on all of the following: a. The enrollee's medical history. b. Any clinical circumstances unique to the enrollee which are presented by the requesting health care provider. c. Additional clinical information about the enrollee which may be present in the enrollee's medical record.

(3) In addition to the requirements listed in subdivisions (1) and (2), a determination to deny, reduce, or defer a request for prior authorization shall always be made by a licensed physician or other health care professional who is competent to evaluate any recommendation or conclusion of artificial intelligence in the light of the specific clinical issues involved in the health care service requested which are unique to the enrollee's circumstances or as recommended by the treating health care provider.

(c) An insurer shall do all of the following: (1) Make prominent written disclosure if artificial intelligence is used as a tool to contribute information in utilization review to: a. The sponsor in the case of a group plan; or b. The enrollee in the case of an individual plan.

(3) Ensure that patient data used in utilization review functions by artificial intelligence is not used beyond its intended and stated purpose consistent with the federal Health Insurance Portability and Accountability Act (HIPAA), 42 U.S.C. § 1320d et seq.

(3) A PERSON DESCRIBED IN SUBSECTION (2) OF THIS SECTION THAT USES AN ARTIFICIAL INTELLIGENCE SYSTEM TO CONDUCT UTILIZATION REVIEW SHALL ENSURE THAT: (a) THE ARTIFICIAL INTELLIGENCE SYSTEM BASES ITS DETERMINATION ON THE FOLLOWING INFORMATION, AS APPLICABLE: (I) AN INDIVIDUAL'S MEDICAL OR OTHER CLINICAL HISTORY; (II) INDIVIDUAL CLINICAL CIRCUMSTANCES AS PRESENTED BY THE REQUESTING PROVIDER; AND (III) OTHER RELEVANT CLINICAL INFORMATION CONTAINED IN THE INDIVIDUAL'S MEDICAL OR OTHER CLINICAL RECORD; (b) THE ARTIFICIAL INTELLIGENCE SYSTEM DOES NOT BASE ITS DETERMINATIONS SOLELY ON GROUP DATA, WITHOUT REFERENCE TO THE INDIVIDUAL'S DATA;

(5) (a) NOTWITHSTANDING SUBSECTION (3) OF THIS SECTION, AN ARTIFICIAL INTELLIGENCE SYSTEM MAY BE USED TO ASSIST WITH UTILIZATION REVIEW, INCLUDING EXPEDITED APPROVALS. (b) A CARRIER'S DENIAL OF COVERAGE BASED IN WHOLE OR IN PART ON MEDICAL NECESSITY SHALL NOT BE ISSUED SOLELY ON THE OUTPUT OF AN ARTIFICIAL INTELLIGENCE SYSTEM WITHOUT HUMAN REVIEW AND APPROVAL OF THE DENIAL BY A LICENSED CLINICIAN, LICENSED PHYSICIAN, OR OTHER REGULATED PROFESSIONAL THAT IS COMPETENT TO EVALUATE THE SPECIFIC CLINICAL ISSUES INVOLVED IN THE HEALTH-CARE SERVICES REQUESTED BY THE PROVIDER AND A REVIEW OF THE HEALTH BENEFIT PLAN'S TERMS OF COVERAGE FOR THE HEALTH-CARE SERVICE.

(f) THE ARTIFICIAL INTELLIGENCE SYSTEM'S PERFORMANCE, USE, AND OUTCOMES ARE PERIODICALLY REVIEWED TO MAXIMIZE ACCURACY AND RELIABILITY;

(g) AN INDIVIDUAL'S HEALTH DATA IS NOT USED BEYOND ITS INTENDED OR STATED PURPOSE, CONSISTENT WITH APPLICABLE STATE AND FEDERAL LAWS;

(6) (a) A CARRIER OFFERING A HEALTH BENEFIT PLAN ISSUED OR RENEWED IN THE STATE ON OR AFTER THE EFFECTIVE DATE OF THIS SECTION SHALL NOT PROVIDE COVERAGE FOR SERVICES THAT CONSTITUTE PSYCHOTHERAPY SERVICES, AS DEFINED IN SECTION 12-245-202 (14), THAT ARE PROVIDED DIRECTLY TO AN INDIVIDUAL AND THAT ARE CONDUCTED BY AN ARTIFICIAL INTELLIGENCE SYSTEM. (b) SUBSECTION (6)(a) OF THIS SECTION DOES NOT PROHIBIT THE USE OF BILLING SOFTWARE, ELECTRONIC HEALTH RECORDS, VIDEO PLATFORMS, OR OTHER NONTHERAPEUTIC SOFTWARE TOOLS INCIDENT TO SERVICES PROVIDED BY A HUMAN PROVIDER. (c) THE USE OF VIDEOCONFERENCING, MESSAGING PLATFORMS, OR OTHER COMMUNICATIONS SOFTWARE TO ENABLE SUPERVISION OR CONSULTATION BY A LICENSED, REGISTERED, OR CERTIFIED INDIVIDUAL DOES NOT CONSTITUTE SUPERVISION OR CONSULTATION THAT IS CONDUCTED BY AN ARTIFICIAL INTELLIGENCE SYSTEM, AS REFERENCED IN SUBSECTION (6)(a) OF THIS SECTION.

A PAYER OF MENTAL OR BEHAVIORAL HEALTH-CARE SERVICES PROVIDED UNDER THE "COLORADO MEDICAL ASSISTANCE ACT", AS SPECIFIED IN ARTICLES 4, 5, AND 6 OF THIS TITLE 25.5, OR THE "CHILDREN'S BASIC HEALTH PLAN ACT", AS SPECIFIED IN ARTICLE 8 OF THIS TITLE 25.5, SHALL NOT PAY FOR SERVICES THAT CONSTITUTE PSYCHOTHERAPY SERVICES, AS DEFINED IN SECTION 12-245-202 (14), THAT ARE PROVIDED DIRECTLY TO AN INDIVIDUAL AND THAT ARE CONDUCTED BY AN ARTIFICIAL INTELLIGENCE SYSTEM, AS THAT TERM IS DEFINED IN SECTION 10-16-112.7 (1)(b).

Artificial intelligence systems, artificial intelligence, and other software tools may be used to automate tasks, reduce administrative burdens, participate in decision-making processes, and perform other lawful functions; provided, however, that such systems shall not issue an adverse determination to a patient until a natural person qualifying as a private review agent or a utilization review entity conducts a utilization review in which a clinical peer participates. In no event shall artificial intelligence systems, artificial intelligence, or other software tools supersede the judgment of such clinical peer.

Private review agents and utilization review entities may use artificial intelligence systems, artificial intelligence, or other software tools, provided that such systems or tools are a part of a utilization review plan that is in accordance with the standards set forth in this chapter and the rules and regulations adopted by the Commissioner.

2A. A utilization review organization may use an artificial intelligence-based algorithm to provide an initial review of a request for prior authorization, except that, for a prior authorization request for a health care service based on medical necessity, a utilization review organization shall not use an artificial intelligence-based algorithm as the sole basis for the utilization review organization's decision to deny, delay, or downgrade the prior authorization request.

2. A utilization review organization shall not deny or downgrade a request for prior authorization unless all of the following requirements are met: a. The decision to deny or downgrade the request is made by either of the following: (1) A qualified reviewer, if the health care provider requesting prior authorization is a physician. (2) A clinical peer, if the health care provider requesting prior authorization is not a physician. b. The utilization review organization provides the health care provider that requested the prior authorization all of the following: (1) A written statement that cites the specific reasons for the denial or downgrade, including any coverage criteria or limits, or clinical criteria, that the utilization review organization considered or that was the basis for the denial or downgrade. The written statement shall be signed by either of the following: (a) The qualified reviewer that made the denial or downgrade determination, if the health care provider that requested prior authorization is a physician. (b) The clinical peer that made the denial or downgrade determination, if the health care provider that requested prior authorization is not a physician. (2) A written explanation of the utilization review organization's appeals process. The utilization review organization shall also provide the written explanation to the covered person for whom prior authorization was requested. (3) A written attestation that is either of the following: (a) If the health care provider that requested prior authorization is a physician, a written attestation that the qualified reviewer who made the denial or downgrade determination practices in the same or a similar specialty as the health care provider, and has the requisite training and expertise to treat the medical condition that is the subject of the request for prior authorization, including sufficient knowledge to determine whether the health care service is medically necessary or clinically appropriate. The attestation shall include the qualified reviewer's name, national provider identifier, board certifications, specialty expertise, and educational background. (b) If the health care provider that requested prior authorization is not a physician, a written attestation that the clinical peer who made the denial or downgrade determination practices in the same or a similar specialty as the health care provider, and the clinical peer has experience managing the specific medical condition or administering the health care service that is the subject of the request for prior authorization. The attestation shall include the clinical peer's name, national provider identifier, board certifications, specialty expertise, and educational background.

3. A utilization review organization that denies a request for prior authorization shall, no later than seven business days after the date that the utilization review organization notifies the requesting health care provider of the denial, conduct a consultation either in person or remotely, as follows: a. Between the health care provider and a qualified reviewer, if the health care provider requesting prior authorization is a physician. b. Between the health care provider and a clinical peer, if the health care provider requesting prior authorization is not a physician. 4. a. If a utilization review organization's decision to deny or downgrade a request for prior authorization is appealed by the requesting health care provider or covered person, the appeal shall be conducted by either of the following: (1) A qualified reviewer, if the health care provider requesting prior authorization is a physician. (2) A clinical peer, if the health care provider requesting prior authorization is not a physician. b. A qualified reviewer or clinical peer involved in the initial denial or downgrade determination of a request for prior authorization that is the subject of an appeal shall not conduct the appeal. c. When conducting an appeal of a request for prior authorization, the qualified reviewer or clinical peer shall consider the known clinical aspects of the health care services under review, including but not limited to medical records relevant to the covered person's medical condition that is the subject of the health care services for which prior authorization is requested, and any relevant medical literature submitted by the health care provider as part of the appeal.

2A. A utilization review organization may use an artificial intelligence-based algorithm to provide an initial review of a request for prior authorization, except that, for a prior authorization request for a health care service based on medical necessity, a utilization review organization shall not use an artificial intelligence-based algorithm as the sole basis for the utilization review organization's decision to deny, delay, or downgrade the prior authorization request.

2. A utilization review organization shall not deny or downgrade a request for prior authorization unless all of the following requirements are met:
a. The decision to deny or downgrade the request is made by either of the following:
(1) A qualified reviewer, if the health care provider requesting prior authorization is a physician.
(2) A clinical peer, if the health care provider requesting prior authorization is not a physician.
b. The utilization review organization provides the health care provider that requested the prior authorization all of the following:
(1) A written statement that cites the specific reasons for the denial or downgrade, including any coverage criteria or limits, or clinical criteria, that the utilization review organization considered or that was the basis for the denial or downgrade. The written statement shall be signed by either of the following:
(a) The qualified reviewer that made the denial or downgrade determination, if the health care provider that requested prior authorization is a physician.
(b) The clinical peer that made the denial or downgrade determination, if the health care provider that requested prior authorization is not a physician.
(2) A written explanation of the utilization review organization's appeals process. The utilization review organization shall also provide the written explanation to the covered person for whom prior authorization was requested.
(3) A written attestation that is either of the following:
(a) If the health care provider that requested prior authorization is a physician, a written attestation that the qualified reviewer who made the denial or downgrade determination practices in the same or a similar specialty as the health care provider, and has the requisite training and expertise to treat the medical condition that is the subject of the request for prior authorization, including sufficient knowledge to determine whether the health care service is medically necessary or clinically appropriate. The attestation shall include the qualified reviewer's name, national provider identifier, board certifications, specialty expertise, and educational background.
(b) If the health care provider that requested prior authorization is not a physician, a written attestation that the clinical peer who made the denial or downgrade determination practices in the same or a similar specialty as the health care provider, and the clinical peer has experience managing the specific medical condition or administering the health care service that is the subject of the request for prior authorization. The attestation shall include the clinical peer's name, national provider identifier, board certifications, specialty expertise, and educational background.

3. A utilization review organization that denies a request for prior authorization shall, no later than seven business days after the date that the utilization review organization notifies the requesting health care provider of the denial, conduct a consultation either in person or remotely, as follows:
a. Between the health care provider and a qualified reviewer, if the health care provider requesting prior authorization is a physician.
b. Between the health care provider and a clinical peer, if the health care provider requesting prior authorization is not a physician.

4. a. If a utilization review organization's decision to deny or downgrade a request for prior authorization is appealed by the requesting health care provider or covered person, the appeal shall be conducted by either of the following:
(1) A qualified reviewer, if the health care provider requesting prior authorization is a physician.
(2) A clinical peer, if the health care provider requesting prior authorization is not a physician.
b. A qualified reviewer or clinical peer involved in the initial denial or downgrade determination of a request for prior authorization that is the subject of an appeal shall not conduct the appeal.
c. When conducting an appeal of a request for prior authorization, the qualified reviewer or clinical peer shall consider the known clinical aspects of the health care services under review, including but not limited to medical records relevant to the covered person's medical condition that is the subject of the health care services for which prior authorization is requested, and any relevant medical literature submitted by the health care provider as part of the appeal.

(b) A health insurance issuer authorized to do business in this State shall not issue an adverse consumer outcome with regard to the denial, reduction, or termination of health insurance coverage or benefits that result solely from the use or application of any AI system or predictive model. Any decision-making process concerning the denial, reduction, or termination of insurance plans or benefits that results from the use of AI systems or predictive models shall be meaningfully reviewed, in accordance with review procedures established by Department rules, by an individual with authority to override the AI systems and the determinations of the AI systems. When an adverse consumer outcome is an adverse determination regulated under the Managed Care Reform and Patient Rights Act, the individual with authority to override the AI systems and the determinations of the AI systems shall be a clinical peer as required and defined under that Act.

The Department of Insurance may adopt rules that include standards for the full and fair disclosure of a health insurance issuer's use of AI systems that may impact consumers, that set forth the manner, content, and required disclosures including notice before the use of AI systems, notice after an adverse decision, the way personal information is used to inform decisions, a process for correcting inaccurate information, and instructions for appealing decisions.

An insurer authorized to do business in this State shall not issue an adverse consumer outcome with regard to the denial, reduction, or termination of insurance plans or benefits that result solely from the use or application of any AI system or predictive model. Any decision-making process concerning the denial, reduction, or termination of insurance plans or benefits that results from the use of AI systems or predictive models shall be meaningfully reviewed, in accordance with review procedures established by Department rules, by an individual with authority to override the AI systems and their determinations.

The Department of Insurance may adopt rules that include standards for the full and fair disclosure of an insurer's use of AI systems that set forth the manner, content, and required disclosures.

Sec. 20. (a) A utilization review entity must ensure that: (1) all: (A) adverse determinations based on medical necessity are made; and (B) appeals are reviewed and decided; by a clinical peer; and (2) when making an adverse determination based on medical necessity or reviewing and deciding an appeal, the clinical peer is under the clinical direction of a medical director of the utilization review entity who is: (A) responsible for the provision of health care services provided to covered individuals; and (B) a physician licensed in Indiana under IC 25-22.5. (b) An appeal may not be reviewed or decided by a clinical peer who: (1) has a financial interest in the outcome of the appeal; or (2) was involved in making the adverse determination that is the subject of the appeal.

(b) If a health plan utilization review entity makes an adverse determination on a prior authorization request by a covered individual's health care provider, the health plan utilization review entity must offer the covered individual's health care provider the option to request a peer to peer review by a clinical peer concerning the adverse determination. (c) A covered individual's health care provider may request a peer to peer review by a clinical peer either in writing or electronically. (d) If a peer to peer review by a clinical peer is requested under this section: (1) the utilization review entity's clinical peer and the covered individual's health care provider or the health care provider's designee shall make every effort to provide the peer to peer review not later than forty-eight (48) hours (excluding weekends and state and federal legal holidays) after the utilization review entity receives the request by the covered individual's health care provider for a peer to peer review if the utilization review entity has received the necessary information for the peer to peer review; and (2) the utilization review entity must have the peer to peer review conducted between the clinical peer and the covered individual's health care provider or the provider's designee.

Sec. 21. A clinical peer who: (1) makes an adverse determination; or (2) reviews and decides an appeal; owes a duty to the covered individual to exercise the applicable standard of care.

(c) If a utilization review entity issues an adverse determination in a response under subsection (b), the response must include the following information: (1) Specific reasons for the adverse determination. (2) Suggested alternatives to the requested health care service.

Sec. 19. (a) A utilization review entity shall make any current prior authorization requirements and restrictions, including written clinical criteria, readily accessible on the utilization review entity's website to covered individuals, health care providers, and the general public. The prior authorization requirements and restrictions must be described in detail and in easily understandable language. (b) A utilization review entity may not implement a new prior authorization requirement or restriction or amend an existing requirement or restriction unless: (1) the utilization review entity's website has been updated to reflect the new or amended requirement or restriction; and (2) the utilization review entity provides written notice to covered individuals and health care providers at least sixty (60) days before the requirement or restriction is implemented.

(1) Each health insurer and utilization review organization shall ensure that the artificial intelligence, algorithm or other software tool used to review and approve, modify and delay or deny requests by providers: (A) Makes a determination based on the following information, as applicable: (i) An enrollee's medical or other clinical history; (ii) individual clinical circumstances as presented by the requesting healthcare provider; and (iii) other relevant clinical information contained in the enrollee's medical or other clinical record; (B) does not make a determination based solely on a group dataset; (2) Notwithstanding the provisions of paragraph (1), the artificial intelligence, algorithm or other software tool shall not deny, delay or modify healthcare 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 healthcare professional who is competent to evaluate the specific clinical issues involved in the healthcare services requested by the healthcare provider by reviewing and considering such healthcare provider's recommendation, the enrollee's medical or other clinical history, as applicable, and individual clinical circumstances.

No individual, other than a licensed physician or a licensed healthcare professional who is competent to evaluate the specific clinical issues involved in the healthcare services requested by the provider, shall deny or modify requests for authorization of healthcare services for an enrollee for reasons of medical necessity.

Each health insurer and utilization review organization shall ensure that the artificial intelligence, algorithm or other software tool used to review and approve, modify and delay or deny requests by providers: (C) does not supplant healthcare provider decision-making; (D) does not discriminate, directly or indirectly, against enrollees in violation of state or federal law; (E) is fairly and equitably applied, in accordance with any applicable regulations or guidance issued by the United States department of health and human services; (F) is periodically reviewed and revised to maximize accuracy and reliability; (G) uses patient data in compliance with the health insurance portability and accountability act of 1996, public law 104-191; and (H) does not directly or indirectly cause harm to the enrollee.

(e) Each health insurer subject to this act shall establish written policies and procedures that: (1) Describe the process by which the health benefit plan prospectively, retrospectively or concurrently reviews and approves, modifies and delays or denies requests, based in whole or in part on medical necessity, by healthcare providers of healthcare services for health benefit plan enrollees; and (2) require decisions to be based on the medical necessity of proposed healthcare services are consistent with criteria or guidelines that are supported by clinical principles and processes.

(f) (1) Each health insurer subject to this act shall file with the department such health insurer's policies and procedures establishing the process by which such health insurer prospectively, retrospectively or concurrently reviews and approves, modifies and delays or denies requests, based in whole or in part on medical necessity, by providers of healthcare services for health benefit plan enrollees. (2) Pursuant to paragraph (1), such policies and procedures shall ensure that healthcare decisions based on the medical necessity of proposed healthcare services are consistent with criteria or guidelines that are supported by clinical principles and processes. (3) Each health insurer shall disclose such policies and procedures to insureds, healthcare providers and the public upon request.

C.(1) No entity subject to this Section shall utilize an artificial intelligence or an automated decision system that does any of the following: (a) Engages in discrimination that is prohibited by federal or state law. (b) Violates regulations or guidance disseminated by the United States Department of Health and Human Services. (c) Delays, denies, or modifies healthcare services.

(2) Artificial intelligence or an automated decision system used in the determination process shall not base its determination or determination recommendation solely on a group data set. (3) Artificial intelligence or an automated decision system shall base its determination or determination recommendation on any the following: (a) The insured's medical or other clinical history. (b) Individual clinical circumstances as presented by a requesting provider. (c) Other relevant clinical information contained in the insured's medical or other clinical history.

D.(1)(a) An entity subject to this Section shall not replace the role of a healthcare provider in the determination process with artificial intelligence or an automated decision system. (b) Any adverse determination shall be signed by a licensed physician who personally reviewed the medical record and is responsible for the clinical judgment. (2) An entity subject to this Section shall do all of the following: (a) Require independent judgment from human utilization review personnel in the utilization review process before making an adverse determination for either of the following: (i) Any claim submitted by a provider based on medical necessity. (ii) Any claim submitted by a provider for a procedure requiring prior authorization.

(c) Review the performance, use, and outcomes of an artificial intelligence or an automated decision system at a minimum of once per quarter, and revise the policies and procedures as needed to ensure compliance with this Section.

(d) Use patient data within its intended and stated purpose consistent with the federal Health Insurance Portability and Accountability Act of 1996, as applicable.

(3)(a) A health insurance issuer shall disclose to the enrollee and the department when artificial intelligence or an automated decision system was used in any part of a coverage determination or utilization review. (b) The health insurance issuer shall document the extent to which any artificial intelligence or automated decision system influenced the determination.

(2) A health insurance issuer shall include in its written or electronic notification of an adverse determination all of the reasons for the determination, including the clinical rationale, and the instructions for initiating an appeal or reconsideration of the determination, and whether artificial intelligence or an automated decision system, as defined in R.S. 22:1260.49, was used in the determination process.

F.(1) An entity subject to this Section shall allow the commissioner to inspect and audit the artificial intelligence or automated decision system for compliance with this Section and review policies and procedures for how the artificial intelligence or automated decision system is used in the determination process. (2) The commissioner may require submission and independent review of any artificial intelligence or automated decision system used in utilization review. (3) Upon request of the commissioner, a health insurance issuer shall disclose the data sources, training parameters, and validation methods used to develop any artificial intelligence or automated decision system used in coverage determinations. (4) The health insurance issuer shall pay for any independent review that the commissioner deems necessary.

(A) The artificial intelligence, algorithm, or other software tool bases its determination on the following information, as applicable: (i) An insured's medical or other clinical history. (ii) Individual clinical circumstances as presented by the requesting provider. (iii) Other relevant clinical information contained in the insured's medical or other clinical record. (B) The artificial intelligence, algorithm, or other software tool does not base its determination solely on a group dataset.

(D) The artificial intelligence, algorithm, or other software tool does not supplant health care provider decision-making. (2) Notwithstanding paragraph (1), the artificial intelligence, algorithm, or other software tool 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, as provided in subsection (a), by reviewing and considering the requesting providers recommendation, the insured's medical or other clinical history, as applicable, and individual clinical circumstances.

(G) The artificial intelligence, algorithm, or other software tool is open to inspection for audit or compliance reviews by the division and by the executive office of health and human services pursuant to applicable state and federal law.

(H) Disclosures pertaining to the use and oversight of the artificial intelligence, algorithm, or other software tool are contained in the written policies and procedures, as required by subsection (a).

(I) The artificial intelligence, algorithm, or other software tools performance, use, and outcomes are periodically reviewed and revised to maximize accuracy and reliability.

(J) Patient data is not used beyond its intended and stated purpose, and consistent with state and federal law.

(A) The artificial intelligence, algorithm, or other software tool bases its determination on the following information, as applicable: (i) An insured's medical or other clinical history. (ii) Individual clinical circumstances as presented by the requesting provider. (iii) Other relevant clinical information contained in the insured's medical or other clinical record. (B) The artificial intelligence, algorithm, or other software tool does not base its determination solely on a group dataset.

(2) Notwithstanding paragraph (1), the artificial intelligence, algorithm, or other software tool 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, as provided in subsection (a), by reviewing and considering the requesting providers recommendation, the insured's medical or other clinical history, as applicable, and individual clinical circumstances.

(I) The artificial intelligence, algorithm, or other software tools performance, use, and outcomes are periodically reviewed and revised to maximize accuracy and reliability.

(J) Patient data is not used beyond its intended and stated purpose, and consistent with state and federal law.

(G) The artificial intelligence, algorithm, or other software tool is open to inspection for audit or compliance reviews by the division and by the executive office of health and human services pursuant to applicable state and federal law. (H) Disclosures pertaining to the use and oversight of the artificial intelligence, algorithm, or other software tool are contained in the written policies and procedures, as required by subsection (a).

(D) The artificial intelligence, algorithm, or other software tool does not supplant health care provider decision-making.

(c) Subject to subsection (d) of this section, an entity subject to this section shall ensure that: (1) an artificial intelligence, algorithm, or other software tool bases its determinations on: (i) an enrollee's medical or other clinical history; (ii) individual clinical circumstances as presented by a requesting provider; or (iii) other relevant clinical information contained in the enrollee's medical or other clinical record; (2) an artificial intelligence, algorithm, or other software tool does not base its determinations solely on a group dataset;

(4) an artificial intelligence, algorithm, or other software tool does not replace the role of a health care provider in the determination process under § 15–10B–07 of this subtitle; (d) An artificial intelligence, algorithm, or other software tool may not deny, delay, or modify health care services.

(10) patient data is not used beyond its intended and stated purpose, consistent with the federal Health Insurance Portability and Accountability Act of 1996, as applicable;

(7) an artificial intelligence, algorithm, or other software tool is open to inspection for audit or compliance reviews by the Commissioner IN ACCORDANCE WITH SUBSECTION (E) OF THIS SECTION; (8) written policies and procedures are included in the utilization plan submitted under § 15–10B–05 of this subtitle, including how an artificial intelligence, algorithm, or other software tool will be used and what oversight will be provided; (E) AN AUDIT OR COMPLIANCE REVIEW OF AN ARTIFICIAL INTELLIGENCE, ALGORITHM, OR OTHER SOFTWARE TOOL UNDER SUBSECTION (C)(7) OF THIS SECTION SHALL INCLUDE THE HUMAN EVALUATION OF A PATIENT'S MEDICAL RECORDS BY A LICENSED HEALTH CARE PROFESSIONAL THAT TAKES INTO CONSIDERATION THE PATIENT'S SPECIFIC CIRCUMSTANCES AND ALLOWS THE LICENSED HEALTH CARE PROFESSIONAL TO QUESTION, MODIFY, OR OVERRIDE A DETERMINATION MADE BY THE ARTIFICIAL INTELLIGENCE, ALGORITHM, OR OTHER SOFTWARE TOOL.

(9) the performance, use, and outcomes of an artificial intelligence, algorithm, or other software tool are reviewed and revised, if necessary and at least on a quarterly basis, to maximize accuracy and reliability, IN ACCORDANCE WITH SUBSECTION (F) OF THIS SECTION; (F) A REVIEW OF THE PERFORMANCE, USE, AND OUTCOMES OF ARTIFICIAL INTELLIGENCE, ALGORITHM, OR OTHER SOFTWARE TOOLS UNDER SUBSECTION (C)(9) OF THIS SECTION SHALL INCLUDE: (1) A HUMAN EVALUATION OF THE REAL–WORLD HEALTH OUTCOMES OF DECISIONS MADE BY THE ARTIFICIAL INTELLIGENCE, ALGORITHM, OR OTHER SOFTWARE TOOL; AND (2) USE OF THE FINDINGS MADE BY THE EVALUATION REQUIRED UNDER ITEM (1) OF THIS SUBSECTION TO IMPROVE THE ARTIFICIAL INTELLIGENCE, ALGORITHM, OR OTHER SOFTWARE TOOL AND MAKE THE DECISIONS OF THE ARTIFICIAL INTELLIGENCE, ALGORITHM, OR OTHER SOFTWARE TOOL SAFER, MORE ACCURATE, AND MORE RESPONSIVE TO PATIENT NEEDS.

(VI) FOR A GRIEVANCE RESULTING FROM AN ADVERSE DECISION MADE USING ARTIFICIAL INTELLIGENCE, ALGORITHM, OR OTHER SOFTWARE TOOLS, PROVIDE FOR THE HUMAN REVIEW OF THE ADVERSE DECISION, INCLUDING FOR COMPLIANCE WITH § 15–10B–05.1 OF THIS TITLE.

(3) IF, WITHIN A 6–MONTH PERIOD, MORE THAN A SPECIFIED PERCENTAGE, AS DETERMINED BY THE COMMISSIONER, OF A CARRIER'S ADVERSE DECISIONS MADE USING THE SAME ARTIFICIAL INTELLIGENCE, ALGORITHM, OR SOFTWARE TOOL RESULT IN A GRIEVANCE, THE CARRIER SHALL PROVIDE FOR A MODEL REVIEW PROCESS OF THE ARTIFICIAL INTELLIGENCE, ALGORITHM, OR SOFTWARE TOOL AND SUBMIT THE FINDINGS IN THE REPORT REQUIRED UNDER PARAGRAPH (1) OF THIS SUBSECTION.

(c) Subject to subsection (d) of this section, an entity subject to this section shall ensure that: (1) an artificial intelligence, algorithm, or other software tool bases its determinations on: (i) an enrollee's medical or other clinical history; (ii) individual clinical circumstances as presented by a requesting provider; or (iii) other relevant clinical information contained in the enrollee's medical or other clinical record; (2) an artificial intelligence, algorithm, or other software tool does not base its determinations solely on a group dataset;

(4) an artificial intelligence, algorithm, or other software tool does not replace the role of a health care provider in the determination process under § 15–10B–07 of this subtitle; ... (d) An artificial intelligence, algorithm, or other software tool may not deny, delay, or modify health care services.

(7) an artificial intelligence, algorithm, or other software tool is open to inspection for audit or compliance reviews by the Commissioner; (8) written policies and procedures are included in the utilization plan submitted under § 15–10B–05 of this subtitle, including how an artificial intelligence, algorithm, or other software tool will be used and what oversight will be provided;

Determinations derived from the use of artificial intelligence, including algorithms and other software tools, must: (1) Be based upon an enrollee's medical history, as applicable, and individual clinical circumstances as presented by the requesting provider, as well as other relevant clinical information contained in the enrollee's medical record, and not supplant provider decision making;

A denial, delay, modification or adjustment of health care services based on medical necessity must be made by a clinical peer competent to evaluate the specific clinical issues involved in the health care services requested by the enrollee's provider. The clinical peer making the medical review or utilization review determination shall consider the enrollee's provider's recommendation and the enrollee's medical history, as applicable, and individual clinical circumstances.

Determinations derived from the use of artificial intelligence, including algorithms and other software tools, must: (4) Be open to inspection, and the use of artificial intelligence must be disclosed in the written policies and procedures to an enrollee.

Use of artificial intelligence pursuant to this paragraph must be governed by policies that establish accountability for performance, use and outcomes that are reviewed and revised for accuracy and reliability. Data under this paragraph may not be used beyond its intended and stated purpose. Data under this paragraph must be protected from risk that may directly or indirectly cause harm to the enrollee.

Sec. 3406ss. An insurer that delivers, issues for delivery, or renews in this state a health insurance policy shall not deny, modify, or delay a claim based on a review using artificial intelligence.

Sec. 107b. The department or a contracted health plan shall not deny, modify, or delay a claim under the medical assistance program based on a review using artificial intelligence.

(a) The use of artificial intelligence is prohibited in utilization review. Without limiting the generality of the foregoing, a utilization review organization is prohibited from using artificial intelligence in any part of its review, evaluation, determination, or appeals processes. (b) Notwithstanding section 62M.14, any adverse determination made in violation of this section is null and void.

(a) A physician must review and make the adverse determination under section 62M.05 in all cases in which the utilization review organization has concluded that an adverse determination for clinical reasons is appropriate. (b) The physician conducting the review and making the adverse determination must: (1) hold a current, unrestricted license to practice medicine in this state; and (2) have the same or similar medical specialty as a provider that typically treats or manages the condition for which the health care service has been requested. (f) The physician must attest in writing that artificial intelligence was not used in the utilization review process. Notwithstanding section 62M.14, any adverse determination made in violation of this paragraph is null and void.

(1) A health insurance issuer as defined in 33-22-140 that uses artificial intelligence, an algorithm, or other software tool for the purpose of utilization review or utilization management functions, based in whole or in part on medical necessity, shall comply with this section and shall ensure all of the following: (a) the artificial intelligence, algorithm, or other software tool bases its determination on the following information, as applicable: (i) a covered person's medical or other clinical history; (ii) individual clinical circumstances as presented by the requesting provider; and (iii) other relevant clinical information contained in the covered person's medical or other clinical record; (b) the artificial intelligence, algorithm, or other software tool does not base its determination solely on a group dataset;

(2) Notwithstanding subsection (1), the artificial intelligence, algorithm, or other software tool may not deny, delay, or modify health care services based, in whole or in part, on medical necessity. A determination of medical necessity must 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, as provided in subsection (1)(a)(ii), by reviewing and considering the requesting provider's recommendation, the enrollee's medical or other clinical history, as applicable, and individual clinical circumstances.

(d) the artificial intelligence, algorithm, or other software tool does not supplant health care provider decisionmaking;

(g) the artificial intelligence, algorithm, or other software tool is open to inspection for audit or compliance reviews by the department pursuant to applicable state and federal law;

(h) disclosures pertaining to the use and oversight of the artificial intelligence, algorithm, or other software tool are contained in the written policies and procedures, as required by this section;

(i) the artificial intelligence, algorithm, or other software tool's performance, use, and outcomes are periodically reviewed and revised to maximize accuracy and reliability;

(j) patient data is not used beyond its intended and stated purpose, consistent with the federal Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, and this title, as applicable;

Health carriers are prohibited from using artificial intelligence, as defined in RSA 5-D:1, to conduct audits of provider codes or to adjust such codes based on recommendations from artificial intelligence that would change, alter, or amend the clinical judgment of a provider.

Each carrier shall maintain records identifying the use of artificial intelligence tools in claims processing and make such records available to the insurance department upon audit.

(b) The superintendent shall require all insurers authorized to write accident and health insurance in this state, corporations organized pursuant to article forty-three of this chapter, and a health maintenance organization certified pursuant to article forty-four of the public health law to notify insureds and enrollees about the use or lack of use of artificial intelligence-based algorithms in the utilization review process on the accessible Internet website of such insurer authorized to write accident and health insurance in this state, corporation organized pursuant to article forty-three of this chapter, or health maintenance organization certified pursuant to article forty-four of the public health law.

(c) Every insurer authorized to write accident and health insurance in this state, corporation organized pursuant to article forty-three of this chapter, and health maintenance organization certified pursuant to article forty-four of the public health law shall submit the artificial intelligence-based algorithms and training data sets that are being used or will be used in the utilization review process to the department. The department shall implement a process that allows the department to certify that these artificial intelligence-based algorithms and training data sets have minimized the risk of bias based on the covered person's race, color, religious creed, ancestry, age, sex, gender, national origin, handicap or disability and adhere to evidence-based clinical guidelines.

(d) A clinical peer reviewer who participates in a utilization review process for an insurer authorized to write accident and health insurance in this state, a corporation organized pursuant to article forty-three of this chapter, and a health maintenance organization certified pursuant to article forty-four of the public health law that initially uses artificial intelligence-based algorithms for a utilization review shall open and document the utilization review of the individual clinical records or data prior to issuing an adverse determination.

(1) The artificial intelligence, algorithm, or other software tool bases its determination on the following information, as applicable: (i) An enrollee's medical or dental history; (ii) Individual clinical circumstances as presented by the requesting provider; and (iii) Other relevant clinical information contained in the enrollee's medical or dental record.

(2) The artificial intelligence, algorithm, or other software tool does not supplant health care provider decision making.

(b) Notwithstanding subsection (a) of this section, a denial, delay, or modification of health care services based on medical necessity shall be made by a licensed physician or other health care provider competent to evaluate the specific clinical issues involved in the health care services requested by the provider by considering the requesting provider's recommendation and based on recommendation, the enrollee's medical or dental history, as applicable, and individual clinical circumstances.

(5) The artificial intelligence, algorithm, or other software tool is open to inspection.

(6) Disclosures pertaining to the use and oversight of the artificial intelligence, algorithm, or other software tool are contained in the written policies and procedures.

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

(8) Patient data is not used beyond its intended and stated purpose, consistent with applicable state laws and the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191).

(a) The artificial intelligence, algorithm, or other software tool bases its determination on the following information, as applicable: (i) an enrollee's medical or other clinical history; (ii) individual clinical circumstances as presented by the requesting provider; and (iii) other relevant clinical information contained in the enrollee's medical or other clinical record. (b) The artificial intelligence, algorithm, or other software tool does not base its determination solely on a group dataset.

Notwithstanding subdivision one of this section, the artificial intelligence, algorithm, or other software tool 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, as provided in this title, by reviewing and considering the requesting provider's recommendation, the enrollee's medical or other clinical history, as applicable, and individual clinical circumstances.

The artificial intelligence, algorithm, or other software tool's performance, use, and outcomes are periodically reviewed and revised to maximize accuracy and reliability.

Patient data is not used beyond its intended and stated purpose, consistent with this section and the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191), as applicable.

(g) The artificial intelligence, algorithm, or other software tool is open to inspection for audit or compliance reviews by the department. (h) Disclosures pertaining to the use and oversight of the artificial intelligence, algorithm, or other software tool are contained in the written policies and procedures, as required by section forty-nine hundred two of this title.

The artificial intelligence, algorithm, or other software tool does not supplant health care provider decision-making.

(a) The artificial intelligence, algorithm, or other software tool bases its determination on the following information, as applicable: (i) An insured's medical or other clinical history; (ii) Individual clinical circumstances as presented by the requesting provider; and (iii) Other relevant clinical information contained in the insured's medical or other clinical record. (b) The artificial intelligence, algorithm, or other software tool does not base its determination solely on a group dataset.

Notwithstanding subsection one of this section, the artificial intelligence, algorithm, or other software tool 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 licensed health care professional competent to evaluate the specific clinical issues involved in the health care services requested by the provider, as provided in this title, by reviewing and considering the requesting provider's recommendation, the insured's medical or other clinical history, as applicable, and individual clinical circumstances.

The artificial intelligence, algorithm, or other software tool's performance, use, and outcomes are periodically reviewed and revised to maximize accuracy and reliability.

Patient data is not used beyond its intended and stated purpose, consistent with state law and the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191), as applicable.

(g) The artificial intelligence, algorithm, or other software tool is open to inspection for audit or compliance reviews by the department pursuant to applicable state and federal law. (h) Disclosures pertaining to the use and oversight of the artificial intelligence, algorithm, or other software tool are contained in the written policies and procedures, as required by section forty-nine hundred two of this title.

The artificial intelligence, algorithm, or other software tool does not supplant health care provider decision-making.

(a) The artificial intelligence, algorithm, or other software tool bases its determination on the following information, as applicable: (i) an enrollee's medical or other clinical history; (ii) individual clinical circumstances as presented by the requesting provider; and (iii) other relevant clinical information contained in the enrollee's medical or other clinical record. (b) The artificial intelligence, algorithm, or other software tool does not base its determination solely on a group dataset.

Notwithstanding subdivision one of this section, the artificial intelligence, algorithm, or other software tool 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, as provided in this title, by reviewing and considering the requesting provider's recommendation, the enrollee's medical or other clinical history, as applicable, and individual clinical circumstances.

(i) The artificial intelligence, algorithm, or other software tool's performance, use, and outcomes are periodically reviewed and revised to maximize accuracy and reliability.

(j) Patient data is not used beyond its intended and stated purpose, consistent with this section and the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191), as applicable.

(g) The artificial intelligence, algorithm, or other software tool is open to inspection for audit or compliance reviews by the department. (h) Disclosures pertaining to the use and oversight of the artificial intelligence, algorithm, or other software tool are contained in the written policies and procedures, as required by section forty-nine hundred two of this title.

(a) The artificial intelligence, algorithm, or other software tool bases its determination on the following information, as applicable: (i) An insured's medical or other clinical history; (ii) Individual clinical circumstances as presented by the requesting provider; and (iii) Other relevant clinical information contained in the insured's medical or other clinical record. (b) The artificial intelligence, algorithm, or other software tool does not base its determination solely on a group dataset.

Notwithstanding subsection one of this section, the artificial intelligence, algorithm, or other software tool 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 licensed health care professional competent to evaluate the specific clinical issues involved in the health care services requested by the provider, as provided in this title, by reviewing and considering the requesting provider's recommendation, the insured's medical or other clinical history, as applicable, and individual clinical circumstances.

(i) The artificial intelligence, algorithm, or other software tool's performance, use, and outcomes are periodically reviewed and revised to maximize accuracy and reliability.

(j) Patient data is not used beyond its intended and stated purpose, consistent with state law and the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191), as applicable.

(g) The artificial intelligence, algorithm, or other software tool is open to inspection for audit or compliance reviews by the department pursuant to applicable state and federal law. (h) Disclosures pertaining to the use and oversight of the artificial intelligence, algorithm, or other software tool are contained in the written policies and procedures, as required by section forty-nine hundred two of this title.

(3) The superintendent shall publish a copy of the report on the web site of the department of insurance. The health plan issuer shall publish a copy of the report on the health plan issuer's publicly accessible web site.

(C)(1) No health plan issuer shall make a decision regarding the care of a covered person, including the decision to deny, delay, or modify health care services based on medical necessity, based solely on results derived from the use or application of artificial intelligence.

(2) A determination of medical necessity under a health benefit plan must meet both of the following requirements: (a) The determination is made by a licensed physician or a provider that is qualified to evaluate the specific clinical issues involved in the requested health care services. (b) The determination takes into consideration the requesting provider's recommendation, the covered person's medical or other clinical history, and individual clinical circumstances. (3) Any physician who participates in a determination of medical necessity or a utilization review process on behalf of a health plan issuer shall open and document the review of the individual clinical records or data prior to making an individualized documented decision.

(4) Any decision to deny, delay, or modify health care services covered under a health benefit plan in which an artificial intelligence-based algorithm is used shall be accompanied by a plain language explanation of the rationale used in making the decision.

(3) The superintendent shall publish a copy of the report on the web site of the department of insurance. The health plan issuer shall publish a copy of the report on the health plan issuer's publicly accessible web site.

(C)(1) No health plan issuer shall make a decision regarding the care of a covered person, including the decision to deny, delay, or modify health care services based on medical necessity, based solely on results derived from the use or application of artificial intelligence. (2) A determination of medical necessity under a health benefit plan must meet both of the following requirements: (a) The determination is made by a licensed physician or a provider that is qualified to evaluate the specific clinical issues involved in the requested health care services. (b) The determination takes into consideration the requesting provider's recommendation, the covered person's medical or other clinical history, and individual clinical circumstances. (3) Any physician who participates in a determination of medical necessity or a utilization review process on behalf of a health plan issuer shall open and document the review of the individual clinical records or data prior to making an individualized documented decision.

(4) Any decision to deny, delay, or modify health care services covered under a health benefit plan in which an artificial intelligence-based algorithm is used shall be accompanied by a plain language explanation of the rationale used in making the decision.

A. A utilization review organization, disability insurer, or specialized health insurer that uses an artificial intelligence tool or contracts with or otherwise works through an entity that uses an artificial intelligence tool shall ensure that the artificial intelligence tool: 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;

B. The artificial intelligence tool 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.

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;

10. Requires performance use and outcomes to be periodically reviewed and revised to maximize accuracy and reliability.

C. Any health benefit plan in this state shall notify enrollees and insureds about the use or lack of use of artificial intelligence tools in the utilization review process on the accessible Internet website of such health benefit plan.

8. Is open to inspection for audit or compliance review by the Insurance Commissioner; 9. Contains disclosures pertaining to the use and oversight of the artificial intelligence tool in the written policies and procedures;

(b) Requirements for artificial intelligence-based algorithms.--For each instance in which a facility uses artificial intelligence-based algorithms for clinical decision making, the facility shall comply with the following: (1) The artificial intelligence-based algorithms must not supersede health care provider clinical decision making.

(a) Duty to disclose.--A facility shall disclose to patients of the facility if artificial intelligence-based algorithms are or will be used for clinical decision making or other similar tasks. The disclosure shall be: (1) Provided in all related written communications. (2) Posted on the publicly accessible Internet website of the facility.

(b) Communications.-- (1) A facility that uses artificial intelligence to generate written or verbal patient communications pertaining to patient clinical information shall include: (i) A clear and conspicuous disclaimer that indicates that the communication was generated by artificial intelligence. (ii) Clear instructions on how the patient may contact a human health care provider or relevant employee of the facility with questions. (2) The requirements under paragraph (1) shall not apply to communications that: (i) only pertain to administrative matters, including appointment scheduling, billing or other clerical or business matters; or (ii) have been individually read and reviewed by a human health care provider.

(b) Requirements for artificial intelligence-based algorithms.--For each instance in which an insurer uses artificial intelligence-based algorithms in the utilization review process regarding a covered person, the insurer shall comply with the following: ... (3) The artificial intelligence-based algorithms must not supersede decision making of the health care provider conducting the utilization review.

(1) The artificial intelligence-based algorithms must base a determination on all of the following: (i) The medical or other clinical history of the covered person. (ii) Individual clinical or nonclinical circumstances as presented by the requesting health care provider. (iii) Other relevant clinical or nonclinical information contained in the medical or other clinical record of the covered person. (2) The artificial intelligence-based algorithms must not base a determination solely on a group data set.

§ 5205. Health care provider requirements. Prior to issuing or upholding a decision to deny, reduce or terminate benefits for a health care service, including a decision to deny a prior authorization request, a health care provider who participates in utilization review on behalf of an insurer shall: (1) Review individual clinical records and other relevant information. (2) Document the review under paragraph (1). (3) Based on the review under paragraph (1), exercise judgment independent of any recommendations by the artificial intelligence-based algorithms.

§ 5202. Disclosure. (a) Duty to disclose.--An insurer shall disclose to a participating network provider and all covered persons if artificial intelligence-based algorithms are or will be used in the utilization review process of the insurer. (b) Posting.--An insurer shall post the information about the use of artificial intelligence-based algorithms in the utilization review process of the insurer on the publicly accessible Internet website of the insurer.

§ 5302. Disclosure. (a) Duty to disclose.--An MA or CHIP managed care plan shall disclose to a participating network provider and all enrollees if artificial intelligence-based algorithms are or will be used in the utilization review process of the MA or CHIP managed care plan. (b) Posting.--An MA or CHIP managed care plan shall post the information about the use of artificial intelligence-based algorithms in the utilization review process of the MA or CHIP managed care plan on the publicly accessible Internet website of the MA or CHIP managed care plan.

(b) Requirements for artificial intelligence-based algorithms.--For each instance in which a MA or CHIP managed care plan uses artificial intelligence-based algorithms in the utilization review process regarding an enrollee, the MA or CHIP managed care plan shall comply with the following: (1) The artificial intelligence-based algorithms must base a determination on all of the following: (i) The medical or other clinical history of the enrollee. (ii) Individual clinical or nonclinical circumstances as presented by the requesting health care provider. (iii) Other relevant clinical or nonclinical information contained in the medical or other clinical record of the enrollee. (2) The artificial intelligence-based algorithms must not base a determination solely on a group data set.

(3) The artificial intelligence-based algorithms must not supersede decision making of the health care provider conducting the utilization review.

§ 5305. Health care provider requirements. Prior to issuing or upholding a decision to deny, reduce or terminate benefits for a health care service, including a decision to deny a prior authorization request, a health care provider who participates in utilization review on behalf of an MA or CHIP managed care plan shall: (1) Review individual clinical records and other relevant information. (2) Document the review under paragraph (1). (3) Based on the review under paragraph (1), exercise judgment independent of any recommendations by the artificial intelligence-based algorithms.

(1) The artificial-intelligence-based algorithms must not supersede health care provider clinical decision making.

(3) The artificial-intelligence-based algorithms must not supersede decision making of the health care provider conducting the utilization review.

Prior to issuing or upholding a decision to deny, reduce or terminate benefits for a health care service, including a decision to deny a prior authorization request, a health care provider who participates in utilization review on behalf of an insurer shall: (1) Review individual clinical records and other relevant information. (2) Document the review under paragraph (1). (3) Based on the review under paragraph (1), exercise judgment independent of any recommendations by the artificial-intelligence-based algorithms.

(1) The artificial-intelligence-based algorithms must base a determination on all of the following: (i) The medical or other clinical history of the covered person. (ii) Individual clinical or nonclinical circumstances as presented by the requesting health care provider. (iii) Other relevant clinical or nonclinical information contained in the medical or other clinical record of the covered person. (2) The artificial-intelligence-based algorithms must not base a determination solely on a group data set.

(3) The artificial-intelligence-based algorithms must not supersede decision making of the health care provider conducting the utilization review.

(1) The artificial-intelligence-based algorithms must base a determination on all of the following: (i) The medical or other clinical history of the enrollee. (ii) Individual clinical or nonclinical circumstances as presented by the requesting health care provider. (iii) Other relevant clinical or nonclinical information contained in the medical or other clinical record of the enrollee. (2) The artificial-intelligence-based algorithms must not base a determination solely on a group data set.

Prior to issuing or upholding a decision to deny, reduce or terminate benefits for a health care service, including a decision to deny a prior authorization request, a health care provider who participates in utilization review on behalf of an MA or CHIP managed care plan shall: (1) Review individual clinical records and other relevant information. (2) Document the review under paragraph (1). (3) Based on the review under paragraph (1), exercise judgment independent of any recommendations by the artificial-intelligence-based algorithms.

(1) A facility that uses artificial intelligence to generate written or verbal patient communications pertaining to patient clinical information shall include: (i) A clear and conspicuous disclaimer that indicates that the communication was generated by artificial intelligence. (ii) Clear instructions on how the patient may contact a human health care provider or relevant employee of the facility with questions. (2) The requirements under paragraph (1) shall not apply to communications that: (i) only pertain to administrative matters, including appointment scheduling, billing or other clerical or business matters; or (ii) have been individually read and reviewed by a human health care provider.

(a) Artificial-intelligence-based algorithms.--A facility shall disclose to patients of the facility if artificial-intelligence-based algorithms are or will be used for clinical decision making or other similar tasks. The disclosure shall be: (1) Provided in all related written communications. (2) Posted on the publicly accessible Internet website of the facility.

(a) Artificial-intelligence-based algorithms.--An insurer shall disclose to a participating network provider and all covered persons if artificial-intelligence-based algorithms are or will be used in the utilization review process of the insurer. (b) Posting.--An insurer shall post the information about the use of artificial-intelligence-based algorithms in the utilization review process of the insurer on the publicly accessible Internet website of the insurer.

(a) Artificial-intelligence-based algorithms.--An MA or CHIP managed care plan shall disclose to a participating network provider and all enrollees if artificial-intelligence-based algorithms are or will be used in the utilization review process of the MA or CHIP managed care plan. (b) Posting.--An MA or CHIP managed care plan shall post the information about the use of artificial-intelligence-based algorithms in the utilization review process of the MA or CHIP managed care plan on the publicly accessible Internet website of the MA or CHIP managed care plan.

Any non-administrative adverse benefit determination where an artificial intelligence system made, or was a substantial factor in making, that determination regarding medically necessary care shall be reviewed and approved by a provider with the same license status of the ordering professional provider before being finalized, with documentation of their rationale included in the enrollee's case record. Failure to follow the requirements set forth in this subsection shall result in reversal of the non-administrative adverse determination.

Any non-administrative adverse benefit determination where an artificial intelligence system made, or was a substantial factor in making, that determination regarding medically necessary care shall be reviewed and approved by a provider with the same license status of the ordering professional provider before being finalized, with documentation of their rationale included in the enrollee's case record. Failure to follow the requirements set forth in this subsection shall result in reversal of the non-administrative adverse determination.

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

Any health carrier that makes determinations or provides advice about third-party payment for any health care services using an artificial intelligence, algorithm, or other software tool, for the purpose of utilization review and any health carrier 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 the following: (1) The artificial intelligence, algorithm, or other software tool bases its determination on the following information, as applicable: (a) A patient'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 patient'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;

(3) The artificial intelligence, algorithm, or other software tool is applied equally for all patients, including in accordance with any applicable regulations and guidance issued by the United States Department of Health and Human Services; and (4) The artificial intelligence, algorithm, or other software tool is configured and applied in a standard consistent manner for all subscriber groups and individuals covered by a health benefit plan, as defined in § 58-17-66, so that the resulting decisions are the same for all patients with similar clinical presentations and considerations.

An artificial intelligence, algorithm, or other software tool used for the purpose of utilization review pursuant to section 1 of this Act may not deny, delay, or modify a determination to provide health care services. Any adverse determination may be made only by a licensed physician or a licensed healthcare professional competent to evaluate the specific clinical issues involved in the requested services, and only after reviewing and considering the requesting provider's recommendation, the patient's medical or other clinical history as applicable, and individual clinical circumstances.

(a) A utilization review agent may not use an automated decision system to make, wholly or partly, an adverse determination. (c) This section does not prohibit the use of an algorithm, artificial intelligence system, or automated decision system for administrative support or fraud-detection functions.

(b) The commissioner may audit and inspect at any time a utilization review agent's use of an automated decision system for utilization review.

(a) Notice of an adverse determination must include: (1) the principal reasons for the adverse determination; (2) the clinical basis for the adverse determination; (3) a description of and the source of the screening criteria and review procedures used as guidelines in making the adverse determination; and (4) a description of the procedure for the complaint and appeal process, including notice to the enrollee of the enrollee's right to appeal an adverse determination to an independent review organization and of the procedures to obtain that review.

Each carrier shall (i) publicly disclose, if applicable, to the Bureau the carrier's use of AI to manage insurance claims and coverage, including in underlying algorithms, data used, and resulting determinations; (ii) submit to the Bureau, upon request, all information, including documents and software, necessary for enforcement of this subdivision;

Each carrier shall ... (iv) provide notice to enrollees and health care providers when AI has been used to issue an adverse determination and provide a clear and timely process for appealing the determination.

(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.

The artificial intelligence, algorithm, or other software tool utilized by a health plan 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.

(7) 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.

(5) 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.

(6) 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 plan's written policies and procedures to the extent required by the Department of Financial Regulation.

(a) A health plan, 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 utilization management functions, based in whole or in part on medical necessity, or that contracts with or otherwise works through an entity that uses artificial intelligence, algorithm, or other software tool for the purpose of utilization review or utilization management functions, based in whole or in part on medical necessity, 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) a covered individual'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 covered individual'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. (b) Notwithstanding subsection (a) of this section, the artificial intelligence, algorithm, or other software tool 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 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 covered individual's medical or other clinical history, as appropriate; and the specific clinical circumstances.

(9) The artificial intelligence, algorithm, or other software tool's performance, use, and outcomes are periodically reviewed and revised to maximize accuracy and reliability.

(10) Patient data is not used beyond its intended and stated purpose, consistent with chapter 42B of this title and with the security and privacy protections of 45 C.F.R. Part 160 and 45 C.F.R. Part 164, Subparts A and E, as applicable.

(7) 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. (8) Disclosures pertaining to the use and oversight of the artificial intelligence, algorithm, or other software tool are contained in the health plan's written policies and procedures to the extent required by the Department of Financial Regulation.