This bill mandates that health insurers, referred to as payers, collect and publicly disclose specific data regarding health insurance claims and decisions made through automated utilization management systems. Payers are required to maintain data on various categories of claims, including those submitted for in-network and out-of-network providers, claims that were denied and subsequently appealed, and the procedures for medical specialties with high denial rates. Additionally, if a payer unjustifiably denies at least 20% of claims in a year, they must reimburse the covered person for the denied services. The bill also stipulates that every claim must be reviewed by a medical director, and payers must report their claim rejection rates annually to the Department of Human Services and the Department of Banking and Insurance, as well as disclose this information on their websites.

Furthermore, the bill introduces requirements for transparency in the utilization management process. Medical directors must include their claim denial rates and review times on denial notices, along with instructions for accessing consumer assistance through the Department of Banking and Insurance. Health insurance carriers are also required to disclose whether they use automated utilization management systems and the number of claims reviewed by such systems. The Department of Banking and Insurance is granted the authority to audit these systems and the data collected by payers. The bill defines an automated utilization management system as one that uses specified guidelines, potentially including artificial intelligence, to determine the reimbursement of health care services.