S.B. No. 815 amends the Texas Insurance Code to regulate the use of automated systems in the health benefit claims process, specifically concerning adverse determinations made by utilization review agents. The bill defines "adverse determination" to include decisions that health care services are not medically necessary, appropriate, or are experimental. It introduces new definitions for "algorithm," "artificial intelligence system," and "automated decision system," which are all related to computerized processes that assist in decision-making. Importantly, the bill prohibits utilization review agents from using automated decision systems to make adverse determinations, although such systems can still be used for administrative support or fraud detection.

Additionally, the bill requires that notices of adverse determinations include specific information about the reasons and clinical basis for the decision, as well as the sources of the screening criteria used. The changes will apply to health benefit plans delivered, issued, or renewed on or after January 1, 2026, while plans prior to this date will continue to follow existing laws. The act is set to take effect on September 1, 2025.

Statutes affected:
Introduced: ()
Senate Committee Report: Insurance Code 4201.002, Insurance Code 4201.303 (Insurance Code 4201)
Engrossed: Insurance Code 4201.002, Insurance Code 4201.303 (Insurance Code 4201)
House Committee Report: Insurance Code 4201.002, Insurance Code 4201.303 (Insurance Code 4201)
Enrolled: Insurance Code 4201.002, Insurance Code 4201.303 (Insurance Code 4201)