Health benefit plan providers must ensure that every determination to deny, delay, or modify a prior authorization request based on medical necessity is made by a licensed physician or other health care professional who is competent to evaluate the AI's recommendation or conclusion in light of the specific clinical issues involved in the requested health care service that are unique to the enrollee's circumstances or as recommended by the treating health care provider. AI may not serve as the sole basis for adverse prior authorization determinations.

Carriers may not issue a denial of coverage based in whole or in part on medical necessity solely on the output of an AI system. Every such denial must receive human review and approval by a licensed clinician, licensed physician, or other regulated professional who is competent to evaluate the specific clinical issues involved in the requested health-care services and who reviews the health benefit plan's terms of coverage for the health-care service. AI systems may be used to assist with utilization review, including expedited approvals.

Private review agents and utilization review entities must not issue an adverse determination to a patient based solely on AI systems, artificial intelligence, or other software tools. Before any adverse determination issues, a natural person qualifying as a private review agent or utilization review entity must conduct a utilization review in which a clinical peer participates. AI systems, artificial intelligence, and other software tools may never supersede the judgment of the clinical peer.

Utilization review organizations must not use an AI-based algorithm or system as the sole basis for denying, delaying, or downgrading a prior authorization request based on medical necessity; AI may be used only for initial review.

Utilization review organizations must not deny or downgrade a prior authorization unless the decision is made by a qualified reviewer (for physician requests) or clinical peer (for non-physician requests) who signs a written statement citing specific reasons, provides a written explanation of the appeals process to both the provider and the covered person, and provides a written attestation of their specialty qualifications.

Utilization review agents must not use an automated decision system to make, wholly or partly, any adverse determination regarding medical necessity, appropriateness, or experimental/investigational status of health care services. Automated decision systems remain permitted for administrative support and fraud-detection functions.

Health plans must ensure that AI utilization review tools comply with applicable state and federal law, do not supplant health care provider decision making, do not discriminate directly or indirectly against covered individuals, and are fairly and equitably applied in accordance with applicable HHS regulations and guidance.

AI, algorithms, or other software tools must 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 human health care provider who is competent to evaluate the specific clinical issues involved, by reviewing and considering the requesting provider's recommendation, the covered individual's medical or clinical history, and the specific clinical circumstances. This applies to prospective, retrospective, and concurrent utilization review.

Health carriers must ensure that only a licensed physician or licensed health professional denies a prior authorization request based on medical necessity, after reviewing the requesting provider's recommendation and the enrollee's individual clinical circumstances. AI may not be the sole means used to deny, delay, or modify health care services; algorithms may process and approve requests but may not deny care without human review.

Public employee health plans must ensure that only a licensed physician or licensed health professional denies a prior authorization request based on medical necessity. AI may not be the sole means used to deny, delay, or modify health care services.

Health carriers must not retrospectively deny or modify to less intensive services any previously authorized care based on a changed medical necessity determination. If the authorization was valid under the plan's written policies, the carrier must deem it approved and payable with 1% monthly interest retroactive to submission.

Health insurance issuers must not use any automated process, system, or tool — including artificial intelligence — to downcode a claim.

Health insurance issuers must not issue an adverse consumer outcome — including denial, reduction, or termination of health insurance coverage or benefits — that results solely from the use of any AI system or predictive model. Every AI-informed decision concerning denial, reduction, or termination of coverage or benefits must be meaningfully reviewed by an individual with authority to override the AI system's determinations, in accordance with review procedures established by Department rules. When the adverse consumer outcome is an adverse determination regulated under the Managed Care Reform and Patient Rights Act, the reviewing individual must be a clinical peer as required and defined under that Act.

Health carriers must not use artificial intelligence to conduct audits of provider codes or to adjust provider codes based on AI recommendations where such adjustment would change, alter, or amend the clinical judgment of a provider.

Insurers must ensure that any adverse benefit determination made by an AI system regarding medically necessary care is reviewed and approved by a qualified healthcare professional before being finalized, and must include documentation of the professional's rationale in the enrollee's case record.

Insurers must ensure that any medical-necessity denial where AI made or substantially contributed is reviewed and approved by a provider holding the same license status as the ordering provider before finalization, with the reviewer's rationale documented in the enrollee's case record; otherwise the determination is invalid and must be reconsidered.

Healthcare insurers must not make care decisions or deny, delay, or modify healthcare services based on medical necessity solely on the results of AI; a licensed human clinical professional must make or independently affirm every adverse determination.

Health insurers must not use artificial intelligence as the primary method to deny health insurance claims.

Health insurers must not use artificial intelligence to deny health insurance claims.

Health carriers must ensure that any health insurance claim denial initiated by an automated decision system is reviewed and co-signed by a board-certified specialist in the relevant field before finalization, and must notify enrollees and providers in writing whenever an automated decision system is used at any stage of the coverage determination.

Health carriers must not use an automated adjudication system to downcode or deny a claim unless a clinical reviewer first conducts and documents an individualized review of the claim, supporting medical documentation, and applicable clinical criteria.

Health carriers must not use an automated adjudication system as the sole basis for denying a claim for lack of medical necessity, rejecting a claim for documentation deficiencies, modifying a code without clinical-reviewer verification, or flagging or withholding payment for routine, commonly accepted, or historically validated services.

Utilization review organizations must not use an artificial intelligence-based algorithm as the sole basis for a decision to deny, delay, or downgrade a prior authorization request for a health care service based on medical necessity. AI may be used for initial review, but a human determination is required before any adverse action.

Utilization review organizations must not deny or downgrade a prior authorization request unless: (1) the denial or downgrade decision is made by a qualified reviewer (if the requesting provider is a physician) or a clinical peer (if not a physician); (2) the URO provides the requesting provider a signed written statement citing the specific reasons for the denial or downgrade, including any coverage or clinical criteria considered; (3) the URO provides the requesting provider and the covered person a written explanation of the appeals process; and (4) the URO provides a written attestation that the reviewer practices in the same or similar specialty as the requesting provider and has the requisite training and expertise, including the reviewer's name, national provider identifier, board certifications, specialty expertise, and educational background.

Health insurers and utilization review organizations must not use any AI, algorithm, or software tool to deny, delay, or modify healthcare services based in whole or in part on medical necessity. All medical necessity determinations must be made only by a licensed physician or a licensed healthcare professional who is competent to evaluate the specific clinical issues involved, by reviewing and considering the healthcare provider's recommendation, the enrollee's medical or clinical history, and individual clinical circumstances.

No individual other than a licensed physician or a licensed healthcare professional competent to evaluate the specific clinical issues involved may deny or modify requests for authorization of healthcare services for an enrollee for reasons of medical necessity.

Covered entities must not use any AI or automated decision system in utilization review that (a) engages in discrimination prohibited by federal or state law, (b) violates regulations or guidance from HHS, or (c) delays, denies, or modifies healthcare services.

Covered entities must not replace the role of a healthcare provider in the determination process with AI or an automated decision system. Every adverse determination must be signed by a licensed physician who has personally reviewed the medical record and is responsible for the clinical judgment.

Covered entities must require independent judgment from human utilization review personnel before making any adverse determination on (1) any claim submitted by a provider based on medical necessity or (2) any claim for a procedure requiring prior authorization.

Carriers and utilization review organizations must ensure that AI, algorithms, or software tools used for utilization review do not supplant healthcare provider decision-making.

AI, algorithms, or software tools must not deny, delay, or modify healthcare services based in whole or in part on medical necessity. Medical necessity determinations must be made only by a licensed physician or licensed healthcare professional competent to evaluate the specific clinical issues, who must review and consider the requesting provider's recommendation, the insured's medical or clinical history, and individual clinical circumstances.

Carriers and utilization review organizations must ensure that the AI, algorithm, or other software tool does not supplant health care provider decision-making.

AI, algorithms, or other software tools must 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 requested health care services, who must review and consider the requesting provider's recommendation, the insured's medical or clinical history, and individual clinical circumstances.

Covered entities must ensure that AI, algorithms, or other software tools do not replace the role of a health care provider in the utilization review determination process under § 15–10B–07 of the subtitle.

AI, algorithms, or other software tools may not deny, delay, or modify health care services. All adverse coverage determinations must be made by a human decision-maker.

Carriers must ensure that AI, algorithm, or other software tools do not replace the role of a health care provider in the determination process under § 15–10B–07. A licensed healthcare provider must retain the decision-making role.

An AI, algorithm, or other software tool may not deny, delay, or modify health care services. This is a categorical prohibition — the AI tool itself cannot make adverse coverage determinations.

Health insurers that deliver, issue for delivery, or renew a health insurance policy in Michigan must not deny, modify, or delay any claim based on a review using artificial intelligence.

The Michigan Department of Health and Human Services and any contracted health plan must not deny, modify, or delay a claim under the Medicaid medical assistance program based on a review using artificial intelligence. This is a categorical prohibition — it bars any AI-based review that results in an adverse claims determination, regardless of whether a human also participated in the review.

Utilization review organizations must not use artificial intelligence in any part of their utilization review processes, including review, evaluation, determination, and appeals.

Health carriers must not use any algorithm or artificial intelligence program when making a determination to approve or deny a prior authorization request.

The physician conducting the review and making an adverse determination must attest in writing that artificial intelligence was not used in the utilization review process. Any adverse determination made without this attestation — or where AI was in fact used — is null and void, notwithstanding the existing enforcement framework in section 62M.14.

Utilization review organizations must not use artificial intelligence in any part of the utilization review process, including review, evaluation, determination, and appeals. This is a categorical prohibition — AI may not be used in any capacity, not merely restricted from serving as the sole or primary basis for a decision. Any adverse determination made in violation is null and void, notwithstanding the standard enforcement provisions in section 62M.14. The attorney general may enforce this prohibition under section 8.31.

Health carriers must not use any algorithm or artificial intelligence program when making a determination to approve or deny a prior authorization request.

Insurers using AI in utilization review must ensure adverse determinations are made only by clinical peer reviewers who, prior to issuing a determination, (1) consider the requesting provider's recommendation and the enrollee's individual medical history and clinical circumstances, (2) open and document the review of individual clinical records, and (3) comply with all Article 49 utilization review requirements. Emergency condition determinations must apply a prudent layperson standard to presenting symptoms, regardless of final diagnosis.

An AI-based algorithm must not be the sole basis for an insurer's decision to deny, delay, or modify health care services based on medical necessity.

When an insurer, Article 43 corporation, or HMO initially uses an artificial intelligence-based algorithm for a utilization review, the clinical peer reviewer must open and document a review of the individual's clinical records or data before issuing any adverse determination. The AI algorithm may not serve as the sole basis for the adverse determination without this individualized clinical review.

Health care service plans must ensure that AI, algorithms, or other software tools used in utilization review or utilization management do not supplant health care provider decision making.

Any denial, delay, or modification of health care services based on medical necessity must be made by a licensed physician or other health care provider competent to evaluate the specific clinical issues involved. The reviewing professional must consider the requesting provider's recommendation and base the determination on the enrollee's medical or dental history and individual clinical circumstances.

Utilization review agents must ensure that AI, algorithms, or other software tools used in utilization review do not supplant health care provider decision-making. The tool may inform but not replace the clinical judgment of health care professionals.

Utilization review agents must ensure that AI, algorithms, or other software tools do not deny, delay, or modify health care services based on medical necessity. Medical necessity determinations must be made only by a licensed physician or licensed health care professional competent to evaluate the specific clinical issues involved, who must review and consider the requesting provider's recommendation, the enrollee's medical or clinical history, and the enrollee's individual clinical circumstances.

Disability insurers must ensure that AI, algorithms, or other software tools used in utilization review or utilization management do not supplant health care provider decision-making.

Disability insurers must ensure that AI, algorithms, or other software tools do not deny, delay, or modify health care services based on medical necessity. Medical necessity determinations must be made only by a licensed physician or licensed health care professional competent to evaluate the specific clinical issues involved, who must review and consider the requesting provider's recommendation, the insured's medical or clinical history, and the insured's individual clinical circumstances.

Insurers must ensure that adverse determinations in utilization review processes using AI-based algorithms are made only by clinical peer reviewers who, prior to issuing a determination, consider the treating provider's recommendation and the individual patient's medical history and clinical circumstances, open and document the review of individual clinical records, and apply the prudent layperson standard for emergency conditions without regard to final diagnosis.

Insurers must not use an AI-based algorithm as the sole basis for denying, delaying, or modifying health care services based in whole or in part on medical necessity.

Every clinical peer reviewer participating in an insurer's utilization review process that issues adverse determinations must issue a signed statement in accordance with Insurance Law § 4903(e)(1) or Public Health Law § 4903(5)(a).

Insurers must include in each adverse determination notice the specific coverage or clinical criteria not satisfied, with explicit identification of the relevant language in the criteria relied upon and a clear explanation of the rationale supporting the determination.

Insurers must include in each adverse determination notice a signed statement by the clinical peer reviewer containing their full name, NPI number, credentials, taxonomy code, an attestation of training and impartiality, documentation of time spent reviewing, and an indication of whether they reviewed actual medical records or a prepared summary.

Utilization review agents subject to the Public Health Law must include in each adverse determination notice the specific coverage or clinical criteria not satisfied, with explicit identification of the relevant criteria language and a clear explanation of the rationale.

Utilization review agents subject to the Public Health Law must include in each adverse determination notice a signed statement by the physician containing their full name, NPI number, credentials, taxonomy code, attestation of training and impartiality, documentation of time spent reviewing, and an indication of whether they reviewed actual medical records or a prepared summary.

Utilization review agents must ensure that AI, algorithms, or other software tools used for utilization review do not supplant health care provider decision-making.

AI, algorithms, or other software tools must not deny, delay, or modify health care services based, in whole or in part, on medical necessity. Medical necessity determinations must be made only by a licensed physician or licensed health care professional competent to evaluate the specific clinical issues involved, who must review and consider the requesting provider's recommendation, the enrollee's medical or clinical history, and individual clinical circumstances.

Disability insurers must ensure that AI tools used for utilization review or utilization management do not supplant health care provider decision-making.

AI, algorithms, or other software tools must not deny, delay, or modify health care services based, in whole or in part, on medical necessity. Medical necessity determinations must be made only by a licensed physician or licensed health care professional competent to evaluate the specific clinical issues involved, who must review and consider the requesting provider's recommendation, the insured's medical or clinical history, and individual clinical circumstances.

Health plan issuers must not make any decision regarding the care of a covered person — including any 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.

Health plan issuers must not make any decision regarding the care of a covered person — including decisions 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.

All relevant AI device-generated data must be reviewed for accuracy and validated by a qualified end-user in accordance with deployer-documented policies and procedures before any patient care decisions are rendered.

Utilization review agents must ensure that any adverse determination made by an algorithm, AI system, or automated decision system is reviewed by a qualified human professional before being finalized. Use of these systems for administrative support or fraud detection is permitted without human review.

Utilization review organizations, disability insurers, and specialized health insurers must ensure that the AI tool does not supplant health care provider decision-making.

The AI tool must not deny, delay, or modify health care services based, in whole or in part, on medical necessity. Medical necessity determinations must be made only by a licensed physician or a licensed health care professional competent to evaluate the specific clinical issues involved, who must review and consider the requesting provider's recommendation, the enrollee's medical or clinical history, and individual circumstances.

A clinical peer reviewer participating in a utilization review process where AI tools were initially used must open and document the utilization review of the individual clinical records or data prior to issuing an adverse determination.

Health insurance issuers must not issue any adverse consumer outcome (denial, reduction, or termination of coverage or benefits) resulting from the use of an AI system. All final adverse consumer outcomes must be issued by a licensed professional, and the issuer must provide a disclosure notice to the claimant that the final decision was issued by a professional, not an AI system.

Health insurance issuers must not issue a final adverse consumer outcome on a claim without consulting the claimant's treating provider on medical necessity. All final medical necessity decisions must be made by a licensed health care provider, who must be given the opportunity to review all non-privileged information relating to the claim.

Facilities must ensure that AI-based algorithms used for clinical decision making do not supersede health care provider clinical decision making.

Insurers must ensure that AI-based algorithms used in utilization review do not supersede the decision making of the health care provider conducting the utilization review.

Health care providers conducting utilization review on behalf of an insurer must, before issuing or upholding a decision to deny, reduce, or terminate benefits (including prior authorization denials): (1) review individual clinical records and other relevant information, (2) document the review, and (3) exercise judgment independent of any AI algorithm recommendations.

MA or CHIP managed care plans must ensure that AI-based algorithms used in utilization review do not supersede the decision making of the health care provider conducting the utilization review.

Health care providers conducting utilization review on behalf of an MA or CHIP managed care plan must, before issuing or upholding a decision to deny, reduce, or terminate benefits (including prior authorization denials): (1) review individual clinical records and other relevant information, (2) document the review, and (3) exercise judgment independent of any AI algorithm recommendations.

Facilities must ensure that AI-based algorithms used for clinical decision making do not supersede health care provider clinical decision making. The provider's clinical judgment must remain the final authority.

Insurers must ensure that AI-based algorithms used in utilization review do not supersede the decision making of the health care provider conducting the utilization review.

Before issuing or upholding a decision to deny, reduce, or terminate benefits for a health care service (including denial of a prior authorization request), a health care provider participating in utilization review on behalf of an insurer must: (1) review individual clinical records and other relevant information, (2) document the review, and (3) exercise judgment independent of any AI algorithm recommendations.

MA or CHIP managed care plans must ensure that AI-based algorithms used in utilization review do not supersede the decision making of the health care provider conducting the utilization review.

Before issuing or upholding a decision to deny, reduce, or terminate benefits for a health care service (including denial of a prior authorization request), a health care provider participating in utilization review on behalf of an MA or CHIP managed care plan must: (1) review individual clinical records and other relevant information, (2) document the review, and (3) exercise judgment independent of any AI algorithm recommendations.

Insurers must not rely exclusively on AI or automated decision tools to deny, reduce, or alter coverage or claims for medically necessary care.

Insurers must ensure that any non-administrative adverse benefit determination where AI made or was a substantial factor in the decision regarding medically necessary care is reviewed and approved by a provider with the same license status as the ordering professional provider before the determination is finalized. The reviewing provider's rationale must be documented in the enrollee's case record. Failure to comply results in automatic reversal of the non-administrative adverse determination.

Entities making healthcare coverage decisions must not take any action on a coverage decision that was made based solely on results derived from the use of artificial intelligence or automated decision-making tools.

A healthcare professional (as defined in S.C. Code § 44-30-20) must supervise and meaningfully review any coverage decision made using automated decision-making tools when those tools are used to inform decisions to modify or deny prior authorization or concurrent review requests by providers for health care services to insureds.

Health carriers must not permit an AI, algorithm, or software tool to deny, delay, or modify a determination to provide health care services. Any adverse determination must be made only by a licensed physician or licensed healthcare professional competent to evaluate the specific clinical issues involved, and only after reviewing and considering the requesting provider's recommendation, the patient's medical or clinical history, and individual clinical circumstances.

Utilization review agents must not use an artificial intelligence-based algorithm as the sole basis for any decision to wholly or partly deny, delay, or modify health care services for an enrollee on the basis of medical necessity or appropriateness. Only a physician or licensed health care provider may make medical necessity or appropriateness determinations.

Utilization review agents must ensure that the AI algorithm or tool does not override the decision-making of a physician or health care provider.

Utilization review agents may not use an AI-based algorithm or software tool as the sole basis for denying, delaying, or modifying health care services on the basis of medical necessity or appropriateness. Only a physician or licensed health care provider acting under Chapter 4201 may determine medical necessity or appropriateness.

Utilization review agents that use AI-based algorithms for initial review must require a specialist to open and document the utilization review of the individual's clinical records or data before making any adverse determination against that individual.

Health plans must not use AI, algorithms, or software tools to deny, delay, or modify a determination of whether to authorize health care services coverage. All adverse coverage determinations must be made only by a licensed human health care provider who is competent to evaluate the specific clinical issues involved, by reviewing and considering the requesting provider's recommendation, the insured's medical or clinical history, and the specific clinical circumstances.

Health benefit plan providers must ensure that every determination to deny, delay, or modify a prior authorization request based on medical necessity is made by a licensed physician or other health care professional who is competent to evaluate the AI's recommendation or conclusion in light of the specific clinical issues involved in the requested health care service that are unique to the enrollee's circumstances or as recommended by the treating health care provider. AI may not serve as the sole basis for adverse prior authorization determinations.

Carriers may not issue a denial of coverage based in whole or in part on medical necessity solely on the output of an AI system. Every such denial must receive human review and approval by a licensed clinician, licensed physician, or other regulated professional who is competent to evaluate the specific clinical issues involved in the requested health-care services and who reviews the health benefit plan's terms of coverage for the health-care service. AI systems may be used to assist with utilization review, including expedited approvals.

Private review agents and utilization review entities must not issue an adverse determination to a patient based solely on AI systems, artificial intelligence, or other software tools. Before any adverse determination issues, a natural person qualifying as a private review agent or utilization review entity must conduct a utilization review in which a clinical peer participates. AI systems, artificial intelligence, and other software tools may never supersede the judgment of the clinical peer.

Utilization review organizations must not deny or downgrade a prior authorization unless the decision is made by a qualified reviewer (for physician requests) or clinical peer (for non-physician requests) who signs a written statement citing specific reasons, provides a written explanation of the appeals process to both the provider and the covered person, and provides a written attestation of their specialty qualifications.

Utilization review organizations must, upon provider request, conduct a consultation (in person or remotely) between the requesting provider and the qualified reviewer or clinical peer within seven business days of denial notification.

Utilization review organizations must ensure that appeals of prior authorization denials are conducted by a qualified reviewer or clinical peer who was not involved in the initial determination, and who considers the patient's medical records and any relevant medical literature submitted by the provider.

AI, algorithms, or other software tools must 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 human health care provider who is competent to evaluate the specific clinical issues involved, by reviewing and considering the requesting provider's recommendation, the covered individual's medical or clinical history, and the specific clinical circumstances. This applies to prospective, retrospective, and concurrent utilization review.

Health carriers must ensure that only a licensed physician or licensed health professional denies a prior authorization request based on medical necessity, after reviewing the requesting provider's recommendation and the enrollee's individual clinical circumstances. AI may not be the sole means used to deny, delay, or modify health care services; algorithms may process and approve requests but may not deny care without human review.

Public employee health plans must ensure that only a licensed physician or licensed health professional denies a prior authorization request based on medical necessity. AI may not be the sole means used to deny, delay, or modify health care services.

Health insurance issuers must ensure that all downcoding decisions are made by a physician licensed to practice medicine in all its branches, of the same or similar specialty as the physician who typically manages the medical condition, and who performs a documented review of the clinical information supporting the billed service.

Health insurance issuers must not issue an adverse consumer outcome — including denial, reduction, or termination of health insurance coverage or benefits — that results solely from the use of any AI system or predictive model. Every AI-informed decision concerning denial, reduction, or termination of coverage or benefits must be meaningfully reviewed by an individual with authority to override the AI system's determinations, in accordance with review procedures established by Department rules. When the adverse consumer outcome is an adverse determination regulated under the Managed Care Reform and Patient Rights Act, the reviewing individual must be a clinical peer as required and defined under that Act.

Insurers must ensure that any adverse benefit determination made by an AI system regarding medically necessary care is reviewed and approved by a qualified healthcare professional before being finalized, and must include documentation of the professional's rationale in the enrollee's case record.

Insurers must ensure that any medical-necessity denial where AI made or substantially contributed is reviewed and approved by a provider holding the same license status as the ordering provider before finalization, with the reviewer's rationale documented in the enrollee's case record; otherwise the determination is invalid and must be reconsidered.

Healthcare insurers must ensure that every initial adverse prior authorization determination or appeal is reviewed by an independent licensed physician with relevant clinical expertise who is not employed by or financially interested in the utilization review entity, has not been involved in the initial determination, and has reviewed individual patient medical records, facility records, and provider-submitted medical literature before completing and signing the denial notice.

Healthcare insurers must ensure that adverse medical-necessity determinations are made only by a licensed healthcare professional competent to evaluate the specific clinical issues, who reviews the treating provider's recommendation, the enrollee's individual medical history, and the enrollee's individual clinical circumstances.

Health carriers must ensure that any health insurance claim denial initiated by an automated decision system is reviewed and co-signed by a board-certified specialist in the relevant field before finalization, and must notify enrollees and providers in writing whenever an automated decision system is used at any stage of the coverage determination.

Health carriers must not use an automated adjudication system to downcode or deny a claim unless a clinical reviewer first conducts and documents an individualized review of the claim, supporting medical documentation, and applicable clinical criteria.

Health carriers must accept provider appeals of downcoding or denials submitted within 30 calendar days of the provider's receipt of notice — by additional documentation or by request for clinical-reviewer review — and must respond no later than 45 calendar days after receiving the appeal.

When clinical-reviewer review of an appeal concludes the originally billed code was supported by proper documentation, the health carrier must readjust the claim to the original code and provide the provider with written explanation of the reversal.

Utilization review organizations must not deny or downgrade a prior authorization request unless: (1) the denial or downgrade decision is made by a qualified reviewer (if the requesting provider is a physician) or a clinical peer (if not a physician); (2) the URO provides the requesting provider a signed written statement citing the specific reasons for the denial or downgrade, including any coverage or clinical criteria considered; (3) the URO provides the requesting provider and the covered person a written explanation of the appeals process; and (4) the URO provides a written attestation that the reviewer practices in the same or similar specialty as the requesting provider and has the requisite training and expertise, including the reviewer's name, national provider identifier, board certifications, specialty expertise, and educational background.

When a prior authorization denial or downgrade is appealed by the requesting provider or covered person, the utilization review organization must ensure: (1) the appeal is conducted by a qualified reviewer (if the requesting provider is a physician) or clinical peer (if not); (2) the reviewer who made the initial determination may not conduct the appeal; and (3) the appeal reviewer must consider the known clinical aspects of the services under review, including the covered person's medical records and any relevant medical literature submitted by the provider.

Health insurers and utilization review organizations must not use any AI, algorithm, or software tool to deny, delay, or modify healthcare services based in whole or in part on medical necessity. All medical necessity determinations must be made only by a licensed physician or a licensed healthcare professional who is competent to evaluate the specific clinical issues involved, by reviewing and considering the healthcare provider's recommendation, the enrollee's medical or clinical history, and individual clinical circumstances.

No individual other than a licensed physician or a licensed healthcare professional competent to evaluate the specific clinical issues involved may deny or modify requests for authorization of healthcare services for an enrollee for reasons of medical necessity.

Covered entities must not replace the role of a healthcare provider in the determination process with AI or an automated decision system. Every adverse determination must be signed by a licensed physician who has personally reviewed the medical record and is responsible for the clinical judgment.

AI, algorithms, or software tools must not deny, delay, or modify healthcare services based in whole or in part on medical necessity. Medical necessity determinations must be made only by a licensed physician or licensed healthcare professional competent to evaluate the specific clinical issues, who must review and consider the requesting provider's recommendation, the insured's medical or clinical history, and individual clinical circumstances.

AI, algorithms, or other software tools must 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 requested health care services, who must review and consider the requesting provider's recommendation, the insured's medical or clinical history, and individual clinical circumstances.

Covered entities must ensure that any audit or compliance review of AI utilization review tools includes a licensed health care professional's evaluation of a patient's medical records that (1) takes into consideration the patient's specific circumstances, and (2) allows the licensed health care professional to question, modify, or override any determination made by the AI tool.

Insurers using AI in utilization review must ensure adverse determinations are made only by clinical peer reviewers who, prior to issuing a determination, (1) consider the requesting provider's recommendation and the enrollee's individual medical history and clinical circumstances, (2) open and document the review of individual clinical records, and (3) comply with all Article 49 utilization review requirements. Emergency condition determinations must apply a prudent layperson standard to presenting symptoms, regardless of final diagnosis.

Every clinical peer reviewer participating in utilization review for an insurer must issue a signed statement in accordance with Insurance Law § 4903(e)(1) or Public Health Law § 4903(5)(a).

When an insurer, Article 43 corporation, or HMO initially uses an artificial intelligence-based algorithm for a utilization review, the clinical peer reviewer must open and document a review of the individual's clinical records or data before issuing any adverse determination. The AI algorithm may not serve as the sole basis for the adverse determination without this individualized clinical review.

Any denial, delay, or modification of health care services based on medical necessity must be made by a licensed physician or other health care provider competent to evaluate the specific clinical issues involved. The reviewing professional must consider the requesting provider's recommendation and base the determination on the enrollee's medical or dental history and individual clinical circumstances.

Utilization review agents must ensure that AI, algorithms, or other software tools do not deny, delay, or modify health care services based on medical necessity. Medical necessity determinations must be made only by a licensed physician or licensed health care professional competent to evaluate the specific clinical issues involved, who must review and consider the requesting provider's recommendation, the enrollee's medical or clinical history, and the enrollee's individual clinical circumstances.

Disability insurers must ensure that AI, algorithms, or other software tools do not deny, delay, or modify health care services based on medical necessity. Medical necessity determinations must be made only by a licensed physician or licensed health care professional competent to evaluate the specific clinical issues involved, who must review and consider the requesting provider's recommendation, the insured's medical or clinical history, and the insured's individual clinical circumstances.

Insurers must ensure that adverse determinations in utilization review processes using AI-based algorithms are made only by clinical peer reviewers who, prior to issuing a determination, consider the treating provider's recommendation and the individual patient's medical history and clinical circumstances, open and document the review of individual clinical records, and apply the prudent layperson standard for emergency conditions without regard to final diagnosis.

Insurers must include in each adverse determination notice a signed statement by the clinical peer reviewer containing their full name, NPI number, credentials, taxonomy code, an attestation of training and impartiality, documentation of time spent reviewing, and an indication of whether they reviewed actual medical records or a prepared summary.

Utilization review agents subject to the Public Health Law must include in each adverse determination notice a signed statement by the physician containing their full name, NPI number, credentials, taxonomy code, attestation of training and impartiality, documentation of time spent reviewing, and an indication of whether they reviewed actual medical records or a prepared summary.

AI, algorithms, or other software tools must not deny, delay, or modify health care services based, in whole or in part, on medical necessity. Medical necessity determinations must be made only by a licensed physician or licensed health care professional competent to evaluate the specific clinical issues involved, who must review and consider the requesting provider's recommendation, the enrollee's medical or clinical history, and individual clinical circumstances.

AI, algorithms, or other software tools must not deny, delay, or modify health care services based, in whole or in part, on medical necessity. Medical necessity determinations must be made only by a licensed physician or licensed health care professional competent to evaluate the specific clinical issues involved, who must review and consider the requesting provider's recommendation, the insured's medical or clinical history, and individual clinical circumstances.

Health plan issuers must ensure that every determination of medical necessity under a health benefit plan is (1) made by a licensed physician or a provider qualified to evaluate the specific clinical issues involved in the requested health care services, and (2) takes into consideration the requesting provider's recommendation, the covered person's medical or other clinical history, and individual clinical circumstances.

Health plan issuers must ensure that every determination of medical necessity under a health benefit plan is made by a licensed physician or a provider qualified to evaluate the specific clinical issues involved. The determination must take into consideration the requesting provider's recommendation, the covered person's medical or other clinical history, and individual clinical circumstances.

Any physician who participates in a determination of medical necessity or utilization review on behalf of a health plan issuer must open and document the review of the individual clinical records or data before making an individualized documented decision.

All relevant AI device-generated data must be reviewed for accuracy and validated by a qualified end-user in accordance with deployer-documented policies and procedures before any patient care decisions are rendered.

The AI tool must not deny, delay, or modify health care services based, in whole or in part, on medical necessity. Medical necessity determinations must be made only by a licensed physician or a licensed health care professional competent to evaluate the specific clinical issues involved, who must review and consider the requesting provider's recommendation, the enrollee's medical or clinical history, and individual circumstances.

A clinical peer reviewer participating in a utilization review process where AI tools were initially used must open and document the utilization review of the individual clinical records or data prior to issuing an adverse determination.

Health insurance issuers must not issue a final adverse consumer outcome on a claim without consulting the claimant's treating provider on medical necessity. All final medical necessity decisions must be made by a licensed health care provider, who must be given the opportunity to review all non-privileged information relating to the claim.

Health care providers conducting utilization review on behalf of an insurer must, before issuing or upholding a decision to deny, reduce, or terminate benefits (including prior authorization denials): (1) review individual clinical records and other relevant information, (2) document the review, and (3) exercise judgment independent of any AI algorithm recommendations.

Health care providers conducting utilization review on behalf of an MA or CHIP managed care plan must, before issuing or upholding a decision to deny, reduce, or terminate benefits (including prior authorization denials): (1) review individual clinical records and other relevant information, (2) document the review, and (3) exercise judgment independent of any AI algorithm recommendations.

Before issuing or upholding a decision to deny, reduce, or terminate benefits for a health care service (including denial of a prior authorization request), a health care provider participating in utilization review on behalf of an insurer must: (1) review individual clinical records and other relevant information, (2) document the review, and (3) exercise judgment independent of any AI algorithm recommendations.

Before issuing or upholding a decision to deny, reduce, or terminate benefits for a health care service (including denial of a prior authorization request), a health care provider participating in utilization review on behalf of an MA or CHIP managed care plan must: (1) review individual clinical records and other relevant information, (2) document the review, and (3) exercise judgment independent of any AI algorithm recommendations.

Insurers must ensure that adverse determinations are reviewed by physicians or other licensed healthcare professionals qualified in the appropriate specialties, free from conflicts of interest or incentives to confirm adverse determinations, and with authority to reverse adverse determinations based on clinical judgment.

Insurers must ensure that any non-administrative adverse benefit determination where AI made or was a substantial factor in the decision regarding medically necessary care is reviewed and approved by a provider with the same license status as the ordering professional provider before the determination is finalized. The reviewing provider's rationale must be documented in the enrollee's case record. Failure to comply results in automatic reversal of the non-administrative adverse determination.

A healthcare professional (as defined in S.C. Code § 44-30-20) must supervise and meaningfully review any coverage decision made using automated decision-making tools when those tools are used to inform decisions to modify or deny prior authorization or concurrent review requests by providers for health care services to insureds.

Health carriers must not permit an AI, algorithm, or software tool to deny, delay, or modify a determination to provide health care services. Any adverse determination must be made only by a licensed physician or licensed healthcare professional competent to evaluate the specific clinical issues involved, and only after reviewing and considering the requesting provider's recommendation, the patient's medical or clinical history, and individual clinical circumstances.

Utilization review agents must not use an artificial intelligence-based algorithm as the sole basis for any decision to wholly or partly deny, delay, or modify health care services for an enrollee on the basis of medical necessity or appropriateness. Only a physician or licensed health care provider may make medical necessity or appropriateness determinations.

Utilization review agents may not use an AI-based algorithm or software tool as the sole basis for denying, delaying, or modifying health care services on the basis of medical necessity or appropriateness. Only a physician or licensed health care provider acting under Chapter 4201 may determine medical necessity or appropriateness.

Utilization review agents that use AI-based algorithms for initial review must require a specialist to open and document the utilization review of the individual's clinical records or data before making any adverse determination against that individual.

Health plans must not use AI, algorithms, or software tools to deny, delay, or modify a determination of whether to authorize health care services coverage. All adverse coverage determinations must be made only by a licensed human health care provider who is competent to evaluate the specific clinical issues involved, by reviewing and considering the requesting provider's recommendation, the insured's medical or clinical history, and the specific clinical circumstances.

Health benefit plan providers that use AI to make medical necessity determinations on prior authorization requests must base those determinations on all of the following individualized enrollee data: (1) the enrollee's medical history, (2) any clinical circumstances unique to the enrollee presented by the requesting health care provider, and (3) additional clinical information about the enrollee present in the enrollee's medical record.

Covered entities using AI for utilization review must ensure that the AI system bases its determination on the individual's medical or other clinical history, the individual clinical circumstances as presented by the requesting provider, and other relevant clinical information contained in the individual's medical or other clinical record.

Covered entities must ensure that the AI system does not base its determinations solely on group data without reference to the individual's data.

Any algorithm or decision assistance tool included in an electronic health record to assist a health care practitioner in making medical treatment decisions must include the individual's biological sex as recorded in the EHR.

Health plans using AI, algorithms, or other software tools for utilization review or utilization management based on medical necessity must ensure the tool bases its determination on: (1) the covered individual's medical or clinical history; (2) the specific clinical circumstances as presented by the requesting health care provider; and (3) other relevant clinical information in the individual's medical record. The tool must not base its determination solely on a group dataset.

Health carriers using AI in prior authorization must ensure the AI bases determinations on the enrollee's individual medical or clinical history and clinical circumstances as presented by the requesting provider, and must not base determinations solely on a group data set.

Public employee health plans using AI in prior authorization must ensure the AI bases determinations on the enrollee's individual clinical data (not solely group data sets), does not discriminate, is periodically reviewed for accuracy, is open to audit by the OIC, and limits patient data use to the stated purpose consistent with HIPAA and state privacy law.

Health insurance issuers must ensure that all downcoding decisions are made by a physician licensed to practice medicine in all its branches, of the same or similar specialty as the physician who typically manages the medical condition, and who performs a documented review of the clinical information supporting the billed service.

Health insurance issuers must not downcode a claim based solely on the reported diagnosis codes.

Healthcare insurers using automated decision-making systems must identify and cite peer-reviewed studies assessing the system's accuracy against enrollee outcomes, and those studies must be concordant with or based on publicly accessible evidence-based clinical guidelines rather than proprietary insurer criteria.

Healthcare insurers must ensure that adverse medical-necessity determinations are made only by a licensed healthcare professional competent to evaluate the specific clinical issues, who reviews the treating provider's recommendation, the enrollee's individual medical history, and the enrollee's individual clinical circumstances.

Healthcare insurers must either reference publicly accessible internal coverage criteria based on current evidence in widely used treatment guidelines or clinical literature, or use AI algorithms solely to implement internal coverage criteria that have been made public and adopted in compliance with this subchapter.

Health insurers and utilization review organizations must ensure that any AI, algorithm, or software tool used to review, approve, modify, delay, or deny provider requests: (1) bases determinations on the enrollee's medical or clinical history, individual clinical circumstances as presented by the requesting provider, and other relevant clinical information in the enrollee's record; (2) does not make a determination based solely on a group dataset; (3) does not supplant healthcare provider decision-making; (4) does not discriminate directly or indirectly against enrollees in violation of state or federal law; (5) is fairly and equitably applied in accordance with applicable HHS regulations or guidance; (6) is periodically reviewed and revised to maximize accuracy and reliability; (7) uses patient data in compliance with HIPAA; and (8) does not directly or indirectly cause harm to the enrollee.

Covered entities must ensure that AI or automated decision systems used in the determination process do not base determinations or recommendations solely on group-level datasets. Determinations must be based on the insured's individual medical or clinical history, individual clinical circumstances as presented by the requesting provider, and other relevant clinical information from the insured's records.

Carriers and utilization review organizations must ensure that any AI, algorithm, or software tool used for utilization review or utilization management bases its determinations on the insured's individual medical or clinical history, individual clinical circumstances as presented by the requesting provider, and other relevant clinical information from the insured's record. The tool must not base its determination solely on a group dataset.

Carriers and utilization review organizations must ensure that any AI, algorithm, or other software tool used in utilization review or utilization management bases its determination on the insured's individual clinical data, including: (1) the insured's medical or other clinical history, (2) individual clinical circumstances as presented by the requesting provider, and (3) other relevant clinical information in the insured's medical or clinical record. The tool must not base its determination solely on a group dataset.

Covered entities must ensure that any AI, algorithm, or other software tool used for utilization review bases its determinations on an enrollee's medical or other clinical history, individual clinical circumstances as presented by a requesting provider, or other relevant clinical information contained in the enrollee's medical or clinical record. The tool must not base its determinations solely on a group dataset.

Carriers and entities subject to this section must ensure that AI, algorithm, or other software tools used in utilization review base their 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 in the enrollee's medical or clinical record. The AI tool must not base its determinations solely on a group dataset. The criteria and guidelines for using the AI tool must comply with the requirements of the Insurance title.

Insurers must ensure that AI-based algorithms used in utilization review do not base an adverse determination solely on a group data set — individualized enrollee clinical data must be considered.

Insurers using AI in utilization review must ensure adverse determinations are made only by clinical peer reviewers who, prior to issuing a determination, (1) consider the requesting provider's recommendation and the enrollee's individual medical history and clinical circumstances, (2) open and document the review of individual clinical records, and (3) comply with all Article 49 utilization review requirements. Emergency condition determinations must apply a prudent layperson standard to presenting symptoms, regardless of final diagnosis.

When an insurer, Article 43 corporation, or HMO initially uses an artificial intelligence-based algorithm for a utilization review, the clinical peer reviewer must open and document a review of the individual's clinical records or data before issuing any adverse determination. The AI algorithm may not serve as the sole basis for the adverse determination without this individualized clinical review.

Health care service plans and specialized health care service plans must ensure that any AI, algorithm, or other software tool used for utilization review or utilization management bases its determinations on individualized enrollee clinical data, including: (1) the enrollee's medical or dental history, (2) individual clinical circumstances as presented by the requesting provider, and (3) other relevant clinical information contained in the enrollee's medical or dental record.

Utilization review agents must ensure that any AI, algorithm, or other software tool used in utilization review bases its determination on the individual enrollee's medical or clinical history, the individual clinical circumstances as presented by the requesting provider, and other relevant clinical information contained in the enrollee's medical or clinical record. The tool must not base its determination solely on a group dataset.

Disability insurers must ensure that any AI, algorithm, or other software tool used in utilization review or utilization management bases its determination on the individual insured's medical or clinical history, the individual clinical circumstances as presented by the requesting provider, and other relevant clinical information contained in the insured's medical or clinical record. The tool must not base its determination solely on a group dataset.

Insurers must ensure that AI-based algorithms used in utilization review do not base an adverse determination solely on a group data set.

Utilization review agents must ensure that any AI, algorithm, or other software tool used for utilization review bases its determinations on the individual enrollee's medical or clinical history, clinical circumstances as presented by the requesting provider, and other relevant clinical information in the enrollee's record. The tool must not base its determination solely on a group dataset.

Disability insurers must ensure that any AI, algorithm, or other software tool used for utilization review or utilization management bases its determinations on the individual insured's medical or clinical history, clinical circumstances as presented by the requesting provider, and other relevant clinical information in the insured's record. The tool must not base its determination solely on a group dataset.

Health plan issuers must ensure that every determination of medical necessity under a health benefit plan is (1) made by a licensed physician or a provider qualified to evaluate the specific clinical issues involved in the requested health care services, and (2) takes into consideration the requesting provider's recommendation, the covered person's medical or other clinical history, and individual clinical circumstances.

Any physician who participates in a medical necessity determination or utilization review process on behalf of a health plan issuer must open and document the review of the individual's clinical records or data before making an individualized documented decision.

Health plan issuers must ensure that every determination of medical necessity under a health benefit plan is made by a licensed physician or a provider qualified to evaluate the specific clinical issues involved. The determination must take into consideration the requesting provider's recommendation, the covered person's medical or other clinical history, and individual clinical circumstances.

Utilization review organizations, disability insurers, and specialized health insurers must ensure that any AI tool used in utilization review bases its determinations on individualized enrollee clinical data — including the enrollee's medical or clinical history, individual clinical circumstances as presented by the requesting provider, and other relevant clinical information in the enrollee's record — and does not base its determination solely on a group dataset.

Insurers must ensure that AI-based algorithms used in utilization review base determinations on (i) the covered person's medical or clinical history, (ii) individual clinical or nonclinical circumstances as presented by the requesting health care provider, and (iii) other relevant information in the covered person's clinical record. The algorithms must not base a determination solely on a group data set.

MA or CHIP managed care plans must ensure that AI-based algorithms used in utilization review base determinations on (i) the enrollee's medical or clinical history, (ii) individual clinical or nonclinical circumstances as presented by the requesting health care provider, and (iii) other relevant information in the enrollee's clinical record. The algorithms must not base a determination solely on a group data set.

Insurers must ensure that AI-based algorithms used in utilization review base determinations on the covered person's individual medical or clinical history, the individual clinical or nonclinical circumstances presented by the requesting health care provider, and other relevant clinical or nonclinical information in the covered person's medical record. AI-based algorithms must not base a determination solely on a group data set.

MA or CHIP managed care plans must ensure that AI-based algorithms used in utilization review base determinations on the enrollee's individual medical or clinical history, the individual clinical or nonclinical circumstances presented by the requesting health care provider, and other relevant clinical or nonclinical information in the enrollee's medical record. AI-based algorithms must not base a determination solely on a group data set.

Health carriers must ensure that any AI, algorithm, or software tool used for utilization review bases its determinations on individual patient clinical data, including: (1) the patient's medical or other clinical history, (2) individual clinical circumstances as presented by the requesting provider, and (3) other relevant clinical information in the patient's medical or clinical record. The tool must not base its determination solely on a group dataset.

Utilization review agents must ensure that any AI-based algorithm or software tool used in utilization review bases its determinations on the individual enrollee's medical or clinical history, clinical circumstances as presented by the provider of record, and other relevant clinical information from the enrollee's record — and does not base its determination solely on a group dataset.

Health plans must ensure that any AI, algorithm, or software tool used in utilization review bases its determination on the individual insured's medical or clinical history, the specific clinical circumstances as presented by the requesting health care provider, and other relevant clinical information in the insured's clinical record. The tool must not base its determination solely on a group dataset.

Health benefit plan providers must periodically review their use of artificial intelligence and the outcomes it generates to maximize accuracy and reliability and to ensure the AI used in utilization review continues to comply with the individualized-data, fairness, and nondiscrimination requirements of the act.

Covered entities must periodically review the AI system's performance, use, and outcomes to maximize accuracy and reliability.

Private review agents and utilization review entities may use AI systems, artificial intelligence, or other software tools in utilization review only if those systems or tools are part of a utilization review plan that complies with the standards in Chapter 46 of Title 33 and the rules and regulations adopted by the Commissioner.

Health plans must ensure that AI utilization review tools are periodically reviewed and revised to maximize accuracy and reliability. Patient data must not be used beyond its intended and stated purpose, consistent with state health privacy law and HIPAA privacy and security protections. The AI tool must not directly or indirectly cause harm to the covered individual.

Health carriers must periodically review the AI's performance, use, and outcomes to maximize accuracy and reliability.

Public employee health plans using AI in prior authorization must ensure the AI bases determinations on the enrollee's individual clinical data (not solely group data sets), does not discriminate, is periodically reviewed for accuracy, is open to audit by the OIC, and limits patient data use to the stated purpose consistent with HIPAA and state privacy law.

Healthcare insurers using clinical supervision of AI must provide ongoing education and certification for clinicians reviewing AI determinations to ensure their ability to critically assess AI outputs.

Health insurers and utilization review organizations must ensure that any AI, algorithm, or software tool used to review, approve, modify, delay, or deny provider requests: (1) bases determinations on the enrollee's medical or clinical history, individual clinical circumstances as presented by the requesting provider, and other relevant clinical information in the enrollee's record; (2) does not make a determination based solely on a group dataset; (3) does not supplant healthcare provider decision-making; (4) does not discriminate directly or indirectly against enrollees in violation of state or federal law; (5) is fairly and equitably applied in accordance with applicable HHS regulations or guidance; (6) is periodically reviewed and revised to maximize accuracy and reliability; (7) uses patient data in compliance with HIPAA; and (8) does not directly or indirectly cause harm to the enrollee.

Covered entities must review the performance, use, and outcomes of their AI or automated decision systems at a minimum of once per quarter and revise policies and procedures as needed to ensure compliance.

Carriers and utilization review organizations must periodically review and revise the performance, use, and outcomes of AI, algorithms, or software tools used in utilization review to maximize accuracy and reliability.

Carriers and utilization review organizations must periodically review and revise the performance, use, and outcomes of AI, algorithms, or other software tools used in utilization review to maximize accuracy and reliability.

Covered entities must review and, if necessary, revise the performance, use, and outcomes of AI, algorithms, or other software tools used for utilization review at least on a quarterly basis to maximize accuracy and reliability, in accordance with the human-evaluation requirements of subsection (f).

Covered entities must ensure that any audit or compliance review of AI utilization review tools includes a licensed health care professional's evaluation of a patient's medical records that (1) takes into consideration the patient's specific circumstances, and (2) allows the licensed health care professional to question, modify, or override any determination made by the AI tool.

Covered entities must ensure that the quarterly performance review of AI utilization review tools includes (1) a human evaluation of the real-world health outcomes of decisions made by the AI tool, and (2) use of the findings from that evaluation to improve the AI tool and make its decisions safer, more accurate, and more responsive to patient needs.

Carriers must review and, if necessary, revise the performance, use, and outcomes of AI, algorithm, or other software tools used in utilization review at least quarterly to maximize accuracy and reliability.

Insurers must establish an ongoing quality assurance testing process for all AI-based algorithms with defined safety and efficacy parameters, submit results to the superintendent at least semiannually, and publish the results on a public website within thirty days of submission.

Health care service plans must periodically review and revise the performance, use, and outcomes of any AI, algorithm, or other software tool used in utilization review or utilization management to maximize accuracy and reliability.

Utilization review agents must periodically review and revise the performance, use, and outcomes of AI, algorithms, or other software tools used in utilization review to maximize accuracy and reliability.

Disability insurers must periodically review and revise the performance, use, and outcomes of AI, algorithms, or other software tools used in utilization review or utilization management to maximize accuracy and reliability.

Insurers must establish an ongoing quality assurance testing process for all AI-based algorithms used in utilization review, submit the results to the Superintendent at least semiannually, and publish the results on a public website within thirty days of each submission.

Utilization review agents must periodically review and revise the performance, use, and outcomes of AI tools used for utilization review to maximize accuracy and reliability.

Disability insurers must periodically review and revise the performance, use, and outcomes of AI tools used for utilization review or utilization management to maximize accuracy and reliability.

Utilization review organizations, disability insurers, and specialized health insurers must periodically review and revise the AI tool's performance, use, and outcomes to maximize accuracy and reliability.

Facilities must periodically review and revise the performance, use, and outcomes of AI-based algorithms used for clinical decision making to maximize accuracy and reliability.

Insurers must periodically review and revise the performance, use, and outcomes of AI-based algorithms used in utilization review to maximize accuracy and reliability.

MA or CHIP managed care plans must periodically review and revise the performance, use, and outcomes of AI-based algorithms used in utilization review to maximize accuracy and reliability.

Facilities must periodically review and revise the performance, use, and outcomes of AI-based algorithms used for clinical decision making to maximize accuracy and reliability.

Insurers must periodically review and revise the performance, use, and outcomes of AI-based algorithms used in utilization review to maximize accuracy and reliability.

MA or CHIP managed care plans must periodically review and revise the performance, use, and outcomes of AI-based algorithms used in utilization review to maximize accuracy and reliability.

Insurers must conduct ongoing monitoring, audits, and oversight of all employees and third parties using AI on their behalf to manage enrollee coverage or claims, ensuring that (1) medically necessary care is not delayed, denied, or limited, (2) financial and administrative burdens on enrollees and providers are minimized, (3) private enrollee health information is protected under state and federal privacy law, and (4) AI use does not violate anti-discrimination laws.

Utilization review agents must periodically review and revise the AI algorithm or tool's performance, use, and outcomes to maximize accuracy and reliability.

Health plans must review and revise the performance, use, and outcomes of any AI, algorithm, or software tool used in utilization review at least quarterly to maximize accuracy and reliability.

Health benefit plan providers must ensure that patient data used in AI-driven utilization review functions is not used beyond its intended and stated purpose, consistent with HIPAA.

Covered entities must ensure that an individual's health data is not used beyond its intended or stated purpose, consistent with applicable state and federal laws.

Utilization review organizations must ensure that appeals of prior authorization denials are conducted by a qualified reviewer or clinical peer who was not involved in the initial determination, and who considers the patient's medical records and any relevant medical literature submitted by the provider.

Health plans must ensure that AI utilization review tools are periodically reviewed and revised to maximize accuracy and reliability. Patient data must not be used beyond its intended and stated purpose, consistent with state health privacy law and HIPAA privacy and security protections. The AI tool must not directly or indirectly cause harm to the covered individual.

Health carriers must ensure patient data used by AI in prior authorization is not used beyond its intended and stated purpose, consistent with chapter 70.02 RCW and HIPAA.

Public employee health plans using AI in prior authorization must ensure the AI bases determinations on the enrollee's individual clinical data (not solely group data sets), does not discriminate, is periodically reviewed for accuracy, is open to audit by the OIC, and limits patient data use to the stated purpose consistent with HIPAA and state privacy law.

Registered professional nurses must ensure that vendors or business associates processing data for AI systems comply with all HIPAA, Medical Patient Rights Act, and other applicable confidentiality and privacy obligations.

Registered professional nurses must ensure that vendors or business associates processing data for AI comply with all HIPAA, Medical Patient Rights Act, and other applicable confidentiality and privacy obligations.

Health insurers and utilization review organizations must ensure that any AI, algorithm, or software tool used to review, approve, modify, delay, or deny provider requests: (1) bases determinations on the enrollee's medical or clinical history, individual clinical circumstances as presented by the requesting provider, and other relevant clinical information in the enrollee's record; (2) does not make a determination based solely on a group dataset; (3) does not supplant healthcare provider decision-making; (4) does not discriminate directly or indirectly against enrollees in violation of state or federal law; (5) is fairly and equitably applied in accordance with applicable HHS regulations or guidance; (6) is periodically reviewed and revised to maximize accuracy and reliability; (7) uses patient data in compliance with HIPAA; and (8) does not directly or indirectly cause harm to the enrollee.

Covered entities must use patient data processed by AI or automated decision systems within its intended and stated purpose, consistent with HIPAA.

Carriers and utilization review organizations must ensure that patient data used by AI utilization review tools is not used beyond its intended and stated purpose, consistent with state and federal law.

Carriers and utilization review organizations must ensure that patient data used by AI, algorithms, or other software tools in utilization review is not used beyond its intended and stated purpose, consistent with applicable state and federal law.

Covered entities must ensure that patient data used by AI, algorithms, or other software tools for utilization review is not used beyond its intended and stated purpose, consistent with HIPAA as applicable.

Carriers must ensure that patient data used by AI, algorithm, or other software tools in utilization review is not used beyond its intended and stated purpose, consistent with HIPAA as applicable.

Insurers must not use insured or enrollee data beyond its intended and stated purpose, consistent with HIPAA.

Health care service plans must ensure that patient data used by AI, algorithms, or other software tools in utilization review or utilization management 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.

Utilization review agents must ensure that patient data used by AI, algorithms, or other software tools in utilization review is not used beyond its intended and stated purpose, consistent with HIPAA and applicable provisions of this section.

Disability insurers must ensure that patient data used by AI, algorithms, or other software tools in utilization review or utilization management is not used beyond its intended and stated purpose, consistent with state law and HIPAA.

Insurers must not use insured and enrollee data beyond its intended and stated purpose, consistent with HIPAA.

Utilization review agents must ensure that patient data used by AI tools is not used beyond its intended and stated purpose, consistent with this section and HIPAA.

Disability insurers must ensure that patient data used by AI tools is not used beyond its intended and stated purpose, consistent with state law and HIPAA.

Licensed therapy professionals must execute all necessary HIPAA business associate agreements before using AI in therapy or psychotherapy services.

Licensed therapy professionals must keep all records and all communications with individuals seeking therapy confidential and must not disclose them except as required by R.C. § 5119.28.

Utilization review organizations, disability insurers, and specialized health insurers must ensure that the AI tool does not use patient data beyond its intended and stated purpose, consistent with HIPAA.

Facilities must not use patient data beyond the intended and stated purpose of the AI-based algorithms, consistent with Commonwealth law and HIPAA.

Insurers must not use covered person data beyond the intended and stated purpose of the AI-based algorithms, consistent with Commonwealth law and HIPAA.

MA or CHIP managed care plans must not use enrollee data beyond the intended and stated purpose of the AI-based algorithms, consistent with Commonwealth law and HIPAA.

Facilities must not use patient data beyond the intended and stated purpose of the AI-based algorithms, consistent with Commonwealth law and HIPAA administrative simplification requirements.

Insurers must not use covered person data beyond the intended and stated purpose of the AI-based algorithms, consistent with Commonwealth law and HIPAA administrative simplification requirements.

MA or CHIP managed care plans must not use enrollee data beyond the intended and stated purpose of the AI-based algorithms, consistent with Commonwealth law and HIPAA.

Utilization review agents must ensure that patient information used by the AI algorithm or tool is not used beyond its intended and stated purpose, in accordance with state and federal law.

Health benefit plan providers must make prominent written disclosure regarding their use of artificial intelligence in utilization review in their policies and procedures.

Health care practitioners who use AI for diagnostic purposes must disclose their use of AI technology to their patients.

Utilization review agents must include in every adverse determination notice: (1) the principal reasons for the determination, (2) the clinical basis, (3) a description of and the source of the screening criteria and review procedures used, and (4) a description of the complaint and appeal process including the enrollee's right to appeal to an independent review organization.

Health carriers must post all adjustments to prior authorization policies and procedures — including new applications of prior authorization — in a single location on the carrier's website.

Health insurance issuers must notify physicians of any downcoded claim using appropriate CARC and RARC codes and must provide: (1) the specific reason for downcoding with clinical criteria references, (2) original and revised service codes and payment amounts, (3) the NPI, credentials, and specialty of the reviewing physician, and (4) notice of the right to appeal.

Health insurance issuers must comply with any rules the Department of Insurance adopts regarding disclosure of AI system utilization, including standards for pre-use notice, post-adverse-decision notice, disclosure of how personal information is used to inform decisions, a process for correcting inaccurate information, and instructions for appealing decisions.

Carriers must provide notice to enrollees and health care providers when AI has been used to issue an adverse determination and must provide a clear and timely process for appealing the determination.

Healthcare insurers must disclose, through an applied model card, the strengths, limitations, known biases, performance variability, and population-specific effectiveness of AI-based algorithms used in utilization review to the Insurance Commissioner, in-network providers, enrollees, and the general public on the insurer's website, including algorithm criteria, training data, bias mitigation, applied use cases, outcomes, and any third-party validation results.

Health carriers must ensure that any health insurance claim denial initiated by an automated decision system is reviewed and co-signed by a board-certified specialist in the relevant field before finalization, and must notify enrollees and providers in writing whenever an automated decision system is used at any stage of the coverage determination.

Health carriers must give providers written notice of any intended downcode or denial that includes the originally billed code, the proposed adjusted code or denial reason, the clinical/contractual/administrative justification with policy citation, the responsible clinical reviewer's name and credentials with date and time of review, and a 30-day appeal window before the action is finalized.

Health care providers must disclose to patients when artificial intelligence technology is used to make or inform any decision in the provision of health care, or to generate any part of a communication to the patient regarding their health care, including through a chat bot.

Accident and sickness insurers must disclose to insureds when artificial intelligence technology is used to make or inform any decision in the provision of coverage, or to generate any part of a communication to the insured regarding coverage, including through a chat bot.

Health insurance issuers must disclose to both the enrollee and the Louisiana Department of Insurance when AI or an automated decision system was used in any part of a coverage determination or utilization review.

Health insurance carriers must disclose to insureds whether AI algorithms or automated decision tools are used in the claims review process, including a summary of what tools are used and how they are used throughout claims review.

Carriers and utilization review organizations must include disclosures about the use and oversight of AI, algorithms, or software tools in their written utilization review policies and procedures as required by Chapter 176O § 12(a).

Carriers and utilization review organizations must include disclosures pertaining to the use and oversight of AI, algorithms, or other software tools in their written utilization review policies and procedures as required by Section 12(a) of Chapter 176O.

Insurers must provide written notice to insureds, enrollees, and health care providers about the use of AI-based algorithms in utilization review at the time the algorithm is first adopted and once per subsequent policy period, and must maintain a clear and conspicuous notice on their websites disclosing such use.

Insurers must disclose to the enrollee's health care provider — and upon request to the enrollee — the criteria governing the AI-based algorithm, the training data sets, the algorithm itself, and the outcomes produced by software using the algorithm.

Insurers must include in each adverse determination notice the specific coverage or clinical criteria that were not satisfied, explicit identification of the relevant criteria language, and a clear explanation of why the criteria were deemed unsatisfied.

Utilization review agents subject to Public Health Law must include in each adverse determination notice the specific coverage or clinical criteria not satisfied, explicit identification of the relevant criteria language, and a clear explanation of why the criteria were deemed unsatisfied.

Insurers authorized to write accident and health insurance, Article 43 corporations, and HMOs must notify insureds and enrollees on their publicly accessible websites about the use or lack of use of artificial intelligence-based algorithms in the utilization review process.

Insurers must provide written notice to insureds, enrollees, and health care providers about the use of AI-based algorithms in utilization review when the algorithm is first adopted and once per subsequent policy period, and must maintain a clear and conspicuous notice on their website.

Insurers must disclose to the health care provider — and upon request to the insured or enrollee — the criteria governing the AI algorithm, the training data sets, the algorithm itself, and the outcomes produced by software using the algorithm.

Health plan issuers must accompany any decision to deny, delay, or modify covered health care services in which an AI-based algorithm was used with a plain language explanation of the rationale used in making the decision.

Health plan issuers must accompany any decision to deny, delay, or modify health care services covered under a health benefit plan in which an AI-based algorithm is used with a plain-language explanation of the rationale used in making the decision.

Utilization review agents must include in each adverse determination notice (1) the principal reasons for the determination, (2) the clinical basis, (3) a description and source of the screening criteria and review procedures used, and (4) a description of the complaint and appeal process, including the enrollee's right to appeal to an independent review organization.

Utilization review organizations, disability insurers, and specialized health insurers must include disclosures pertaining to the use and oversight of the AI tool in their written policies and procedures.

Health benefit plans must notify enrollees and insureds about the use or lack of use of AI tools in the utilization review process on the plan's accessible Internet website.

Health insurance issuers must not issue any adverse consumer outcome (denial, reduction, or termination of coverage or benefits) resulting from the use of an AI system. All final adverse consumer outcomes must be issued by a licensed professional, and the issuer must provide a disclosure notice to the claimant that the final decision was issued by a professional, not an AI system.

Facilities must disclose to patients when AI-based algorithms are or will be used for clinical decision making or other similar tasks. The disclosure must be provided in all related written communications and posted on the facility's publicly accessible website.

Insurers must disclose to participating network providers and all covered persons when AI-based algorithms are or will be used in the insurer's utilization review process. The insurer must also post this information on its publicly accessible website.

MA or CHIP managed care plans must disclose to participating network providers and all enrollees when AI-based algorithms are or will be used in the plan's utilization review process. The plan must also post this information on its publicly accessible website.

Facilities must disclose to patients when AI-based algorithms are or will be used for clinical decision making or other similar tasks. The disclosure must be provided in all related written communications and posted on the facility's publicly accessible website.

Insurers must disclose to participating network providers and all covered persons when AI-based algorithms are or will be used in the insurer's utilization review process. The insurer must also post this information on its publicly accessible website.

MA or CHIP managed care plans must disclose to participating network providers and all enrollees when AI-based algorithms are or will be used in the plan's utilization review process. The plan must also post this information on its publicly accessible website.

Insurers must publicly disclose how they use AI to manage claims and coverage, including the underlying algorithms, data used, and resulting determinations.

Insurers must notify enrollees and healthcare providers when AI has been used to issue an adverse determination and must provide a clear and timely process for appealing the determination.

Utilization review agents must disclose in writing to enrollees the use and oversight procedures of the AI algorithm or tool, in the form and manner provided by commissioner rule.

Health benefit plan issuers must publish on a publicly accessible part of their website and provide in writing to each enrollee and to contracting or treating physicians and health care providers a disclosure stating whether the issuer uses or may use AI-based algorithms in its utilization review process.

Covered entities must inform health care professionals and their representatives of the AI/CDSS usage policy, including the presence of AI/CDSS in the workplace and the professional's ability to override an AI/CDSS output.

Health plans must include in their written policies and procedures disclosures pertaining to the use of AI, algorithms, or software tools in the utilization review process and the nature and degree of human review and oversight, to the extent required by the Department of Financial Regulation.

Covered entities must ensure that the AI system produces and retains documentation, audit logs, and model-governance records sufficient to demonstrate compliance with the utilization review requirements of this section and section 10-3-1104.9.

Health plans must ensure that AI utilization review tools are open to inspection for audit or compliance reviews by the Department of Financial Regulation and other state agencies pursuant to applicable law. Disclosures pertaining to the use and oversight of the AI tool must be contained in the health plan's written policies and procedures to the extent required by the Department of Financial Regulation.

Health carriers must ensure their AI policies and procedures for prior authorization are open to audit by the Office of the Insurance Commissioner under chapter 48.37 RCW.

Public employee health plans using AI in prior authorization must ensure the AI bases determinations on the enrollee's individual clinical data (not solely group data sets), does not discriminate, is periodically reviewed for accuracy, is open to audit by the OIC, and limits patient data use to the stated purpose consistent with HIPAA and state privacy law.

Insurers must disclose to OHIC and DBR how they use AI to manage healthcare claims and coverage, including the types of AI models used, AI's role in the decision-making process, training datasets, performance metrics, governance and risk management policies, and which claims and coverage decisions AI made or substantially influenced.

Insurers must retain documentation of AI decisions — including adverse benefit determinations where AI made or was a substantial factor — for at least five years and make it available for regulatory inspection.

Healthcare insurers must disclose, through an applied model card, the strengths, limitations, known biases, performance variability, and population-specific effectiveness of AI-based algorithms used in utilization review to the Insurance Commissioner, in-network providers, enrollees, and the general public on the insurer's website, including algorithm criteria, training data, bias mitigation, applied use cases, outcomes, and any third-party validation results.

Health carriers must disclose to the Iowa Insurance Division their use of automated adjudication systems, including system descriptions, decision criteria and rules, clinical-reviewer oversight processes and audit frequency, and the measures taken to ensure fairness, accuracy, and prevention of unlawful bias or disparate impact.

Health insurers must file with the Kansas Department of Insurance their policies and procedures establishing the process by which the health benefit plan reviews and approves, modifies and delays, or denies requests based in whole or in part on medical necessity. The filed policies must ensure that medical necessity decisions are consistent with criteria or guidelines supported by clinical principles and processes.

Health insurers must disclose their utilization review policies and procedures to insureds, healthcare providers, and the public upon request.

Health insurance issuers must document the extent to which any AI or automated decision system influenced each coverage determination.

Covered entities must allow the Commissioner of Insurance to inspect and audit any AI or automated decision system used in utilization review, including review of all associated policies and procedures. The commissioner may require submission and independent review of any such system, and the health insurance issuer must pay for any independent review the commissioner deems necessary.

Carriers and utilization review organizations must ensure that AI, algorithms, or software tools used in utilization review are open to inspection for audit or compliance reviews by the Division of Occupational Licensure and by the Executive Office of Health and Human Services pursuant to applicable state and federal law.

Carriers and utilization review organizations must ensure that AI, algorithms, or other software tools used in utilization review are open to inspection for audit or compliance reviews by the Division of Insurance and the Executive Office of Health and Human Services pursuant to applicable state and federal law.

Covered entities must ensure that AI, algorithms, or other software tools used for utilization review are open to inspection for audit or compliance reviews by the Maryland Insurance Commissioner, in accordance with the human-evaluation requirements of subsection (e).

Covered entities must include written policies and procedures in the utilization plan submitted under § 15–10B–05, describing how AI, algorithms, or other software tools will be used and what oversight will be provided.

Carriers must ensure that AI, algorithm, or other software tools used in utilization review are open to inspection for audit or compliance reviews by the Maryland Insurance Commissioner.

Carriers must include written policies and procedures in the utilization plan submitted under § 15–10B–05, describing how AI, algorithm, or other software tools will be used and what oversight will be provided.

Insurers must make AI-based algorithms used in utilization review open to inspection for audit or compliance reviews by the superintendent, in accordance with applicable state and federal laws.

Insurers, Article 43 corporations, and HMOs must ensure that the AI-based algorithms and training datasets submitted to the Department have minimized the risk of bias based on race, color, religious creed, ancestry, age, sex, gender, national origin, handicap, or disability, and adhere to evidence-based clinical guidelines, as certified through the Department's bias-certification process.

Health care service plans must ensure that any AI, algorithm, or other software tool used in utilization review or utilization management is open to inspection.

Health care service plans must include disclosures pertaining to the use and oversight of AI, algorithms, or other software tools used in utilization review or utilization management in their written policies and procedures.

Utilization review agents must ensure that AI, algorithms, or other software tools used in utilization review are open to inspection for audit or compliance reviews by the Department of Health.

Utilization review agents must include disclosures pertaining to the use and oversight of AI, algorithms, or other software tools in their written policies and procedures as required by Public Health Law § 4902.

Disability insurers must ensure that AI, algorithms, or other software tools used in utilization review or utilization management are open to inspection for audit or compliance reviews by the Department of Financial Services pursuant to applicable state and federal law.

Disability insurers must include disclosures pertaining to the use and oversight of AI, algorithms, or other software tools in their written policies and procedures as required by Insurance Law § 4902.

Insurers must make all AI-based algorithms used in utilization review open to inspection for audit or compliance reviews by the Superintendent of Financial Services.

Utilization review agents must ensure that AI tools used for utilization review are open to inspection for audit or compliance reviews by the Department of Health.

Utilization review agents must include disclosures pertaining to the use and oversight of AI tools in their written utilization review policies and procedures as required by Public Health Law § 4902.

Disability insurers must ensure that AI tools used for utilization review or utilization management are open to inspection for audit or compliance reviews by the Department of Financial Services pursuant to applicable state and federal law.

Disability insurers must include disclosures pertaining to the use and oversight of AI tools in their written utilization review policies and procedures as required by Insurance Law § 4902.

Health plan issuers must publish a copy of their annual AI utilization review report on the issuer's publicly accessible website. The Superintendent of Insurance must also publish a copy on the Department of Insurance website.

The Superintendent of Insurance must publish a copy of the annual AI utilization review report on the Department of Insurance website. The health plan issuer must also publish a copy of the report on its own publicly accessible website.

Health plan issuers must make their AI-based algorithms available for audit by the Superintendent of Insurance at any time. The superintendent may contract with a third party to conduct such audits.

Utilization review agents must make their use of automated decision systems for utilization review available for audit and inspection by the Insurance Commissioner at any time.

Utilization review organizations, disability insurers, and specialized health insurers must ensure that the AI tool is open to inspection for audit or compliance review by the Insurance Commissioner.

Health carriers must make their automated systems available for inspection by the Division of Insurance at any time to verify compliance with the individualized clinical data requirements and the prohibition on AI-made adverse determinations. If the Division finds noncompliance, the attorney general may direct the health carrier to cease and desist from further noncompliant activities.

Utilization review agents must ensure that the AI algorithm or tool is available for review and inspection under Section 4201.154 of the Insurance Code.

Health plans must ensure that any AI, algorithm, or software tool used in utilization review 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.

Utilization review agents must include in every adverse determination notice: (1) the principal reasons for the determination, (2) the clinical basis, (3) a description of and the source of the screening criteria and review procedures used, and (4) a description of the complaint and appeal process including the enrollee's right to appeal to an independent review organization.

Health carriers must include the credentials, board certifications, and areas of specialty of the provider who had clinical oversight over the determination in every prior authorization denial notification sent to the enrollee and requesting provider.

Health insurance issuers must notify physicians of any downcoded claim using appropriate CARC and RARC codes and must provide: (1) the specific reason for downcoding with clinical criteria references, (2) original and revised service codes and payment amounts, (3) the NPI, credentials, and specialty of the reviewing physician, and (4) notice of the right to appeal.

Health carriers must ensure that any health insurance claim denial initiated by an automated decision system is reviewed and co-signed by a board-certified specialist in the relevant field before finalization, and must notify enrollees and providers in writing whenever an automated decision system is used at any stage of the coverage determination.

Health carriers must give providers written notice of any intended downcode or denial that includes the originally billed code, the proposed adjusted code or denial reason, the clinical/contractual/administrative justification with policy citation, the responsible clinical reviewer's name and credentials with date and time of review, and a 30-day appeal window before the action is finalized.

Health insurance issuers must include in every written or electronic adverse determination notification a statement of whether artificial intelligence or an automated decision system was used in the determination process.

The physician conducting the review and making an adverse determination must attest in writing that artificial intelligence was not used in the utilization review process. Any adverse determination made without this attestation — or where AI was in fact used — is null and void, notwithstanding the existing enforcement framework in section 62M.14.

Insurers must disclose AI use in the written notice of any adverse determination made by clinical peer reviewers, as required by Insurance Law § 4903(e) and Public Health Law § 4903(5).

Each adverse determination notice must include a signed statement from the clinical peer reviewer containing their full name, NPI number, credentials and board certifications, taxonomy code, an attestation of appropriate training and absence of conflicts of interest, documentation of time spent reviewing, and an indication of whether they reviewed actual medical records or a prepared summary.

Each adverse determination notice must include a statement disclosing whether an AI-based algorithm was used in the utilization review process, a plain language explanation of how it was employed, and directions to where the insured and provider can find more information about the specific AI usage.

Each adverse determination notice under Public Health Law must include a signed physician statement containing full name, NPI number, credentials and board certifications, taxonomy code, attestation of training sufficiency and absence of conflicts, time-spent documentation, and indication of whether actual records or a summary were reviewed.

Each adverse determination notice under Public Health Law must disclose whether an AI-based algorithm was used, provide a plain language explanation of how it was employed, and direct the enrollee and provider to more information about the specific AI usage.

Insurers must disclose the use of AI-based algorithms in the utilization review process in the written notice of any adverse determination issued to the insured or enrollee and their health care provider.

Insurers must include in each adverse determination notice a statement as to whether an AI-based algorithm was used in the utilization review process, a plain language explanation of how the algorithm was employed, and information on where the insured and health care provider can find more details about the algorithm's specific usage.

Utilization review agents subject to the Public Health Law must include in each adverse determination notice a statement disclosing whether an AI-based algorithm was used, a plain language explanation of how it was employed, and where to find more information about the algorithm's usage.

Health plan issuers must accompany any decision to deny, delay, or modify health care services covered under a health benefit plan in which an AI-based algorithm is used with a plain-language explanation of the rationale used in making the decision.

Utilization review agents must include in each adverse determination notice (1) the principal reasons for the determination, (2) the clinical basis, (3) a description and source of the screening criteria and review procedures used, and (4) a description of the complaint and appeal process, including the enrollee's right to appeal to an independent review organization.

Health insurance issuers must not issue any adverse consumer outcome (denial, reduction, or termination of coverage or benefits) resulting from the use of an AI system. All final adverse consumer outcomes must be issued by a licensed professional, and the issuer must provide a disclosure notice to the claimant that the final decision was issued by a professional, not an AI system.

Insurers must notify enrollees and healthcare providers when AI has been used to issue an adverse determination and must provide a clear and timely process for appealing the determination.