Bill > SB5395

This bill aims to improve transparency and accountability in the prior authorization process, which is a requirement by health insurance carriers (often called "health plans") before certain medical services or prescription drugs are approved. Key provisions include requiring carriers to provide more detailed information about their prior authorization requirements, including clinical review criteria, and to make these publicly available. The bill also sets stricter timelines for carriers to make prior authorization decisions, especially for urgent requests, and mandates that licensed physicians or health professionals, not solely artificial intelligence (AI), must be responsible for denying requests based on medical necessity. If AI is used, it must adhere to specific standards to ensure it doesn't lead to inappropriate denials and is not the sole basis for denying care. Furthermore, the bill prohibits health plans from retrospectively denying coverage for services that were previously authorized, except in cases of material misrepresentation or lawful rescission of coverage, and it clarifies that certain appeals processes can bypass the carrier's internal grievance procedures. It also enhances reporting requirements for carriers to include data on AI's role in denials and turnaround times, and establishes new electronic processes for determining prior authorization needs for prescription drugs. Some sections of the bill have specific effective and expiration dates, with certain provisions expiring and others taking effect later to allow for implementation.