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 refer to various computerized procedures and systems that can influence decision-making in health care.

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 criteria and procedures 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 law prior to this amendment continuing to govern plans issued before that date. 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)