Bill > AB512

This bill modifies regulations for prior authorization in health care coverage, focusing on the timelines and processes used by health care service plans and disability insurers when reviewing and approving medical service requests. Specifically, the bill reduces the timeframe for standard prior authorization requests from 5 to 3 business days for electronic submissions and from 5 to 5 business days for non-electronic submissions. For urgent cases involving imminent health threats, the bill shortens the review timeline to 24 hours for electronic submissions and 48 hours for non-electronic submissions. The bill also introduces comprehensive regulations for using artificial intelligence (AI) in utilization review, requiring AI tools to base determinations on individual patient clinical information, not supplant healthcare provider decision-making, and ensure non-discriminatory application. Importantly, the bill explicitly states that AI cannot independently deny, delay, or modify healthcare services based on medical necessity - such decisions must be made by a licensed healthcare professional who reviews the specific clinical circumstances. Medi-Cal managed care plans are exempted from these new timeline requirements. The legislation aims to streamline and improve the prior authorization process while introducing safeguards against potentially harmful or biased AI-driven decision-making in healthcare coverage determinations.

Budget and Finance, Health and Social Services

https://leginfo.legislature.ca.gov/faces/billStatusClient.xhtml?bill_id=202520260AB512