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 of 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 physicians or medical directors involved in claim reviews to include their denial rates and review times on denial notices. It also mandates that health insurance carriers 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 utilizes specified guidelines and may incorporate artificial intelligence to assess the allocation of healthcare services under health benefit plans.