S.B. No. 815 aims to regulate the use of automated systems in the health benefit claims process, specifically concerning adverse determinations made by utilization review agents. The bill amends the definition of "adverse determination" to include not only cases where services are deemed not medically necessary but also those considered inappropriate or experimental. It introduces new definitions for "algorithm," "artificial intelligence system," and "automated decision system," which clarify the types of computerized procedures and systems that may be involved in decision-making processes related to health care services.

Additionally, the bill prohibits utilization review agents from using automated decision systems to make adverse determinations, while allowing for audits by the commissioner of such systems. It also mandates that notices of adverse determinations include specific information about the reasons and clinical basis for the decision, as well as the guidelines used in making the determination. The provisions of this bill will apply to health benefit plans delivered or renewed on or after January 1, 2026, with the act taking 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)