This bill introduces new regulations regarding utilization review organizations, prior authorizations, medical billing, and independent review organizations in Iowa. It mandates that health carriers using artificial intelligence (AI) for utilization review must ensure that the AI bases its determinations on specific clinical information and does not replace healthcare provider decision-making. Additionally, the AI must comply with state and federal laws, be open to audits, and not discriminate against covered persons. The bill also stipulates that a determination of medical necessity can only be made by a qualified healthcare provider, and the AI cannot deny or modify healthcare services based on medical necessity.

Furthermore, the bill establishes strict timelines for utilization review organizations to respond to prior authorization requests, requiring responses within 48 hours for urgent requests and 10 days for non-urgent requests. It mandates annual reviews of services requiring prior authorization to eliminate unnecessary requirements and requires health carriers to publish statistics on prior authorization approvals and denials on their websites. The bill also enforces compliance with the federal No Surprises Act and requires independent review organizations and health carriers to submit annual reports to the commissioner of insurance, which will be made publicly accessible. Lastly, it introduces a pilot program for prior authorization exemptions for certain healthcare providers, with detailed reporting requirements to assess the program's effectiveness.

Statutes affected:
Introduced: 514F.8, 514J.114