This bill introduces new regulations regarding the use of artificial intelligence (AI) by utilization review organizations (UROs) in the context of prior authorization determinations and prepayment audits. It allows UROs to utilize AI algorithms for initial reviews of prior authorization requests, but explicitly prohibits the use of AI as the sole basis for denying, delaying, or downgrading requests based on medical necessity. The bill also establishes definitions for terms such as "downgrade" and outlines the requirements for UROs when denying or downgrading requests, including the necessity for decisions to be made by qualified reviewers or clinical peers, and mandates that UROs provide written explanations and conduct consultations within specified timeframes.

Additionally, the bill exempts certain cancer-related screenings and preventative services from prior authorization requirements if recommended by a healthcare professional, aligning with national clinical practice guidelines. It also sets forth procedures for prepayment audits conducted by UROs, including notification timelines and appeal processes for healthcare providers. If a URO fails to comply with these regulations, the claim will be automatically approved. The provisions of the bill will take effect for requests made on or after January 1, 2027, with specific applicability to prior authorization requests made before that date if not yet determined.

Statutes affected:
Introduced: 514F.8