Bill > SF562

Introduced Session

This bill relates to utilization review organizations, prior authorizations and exemptions, medical billing, and independent review organizations. Under the bill, a health carrier (carrier) that uses an artificial intelligence, algorithm, or other software tool (artificial intelligence) for the purpose of utilization review, or that contracts with or works through an entity that uses an artificial intelligence for the purpose of utilization review, shall ensure that (1) the artificial intelligence bases its determination on the information described in the bill; (2) the artificial intelligence does not base its determination solely on a group dataset; (3) the artificial intelligence’s criteria and guidelines comply with Code chapter 514F and applicable state and federal law; (4) the artificial intelligence does not supplant health care provider (provider) decision making; (5) the use of the artificial intelligence does not discriminate against covered persons; (6) the artificial intelligence is fairly and equitably applied; (7) the artificial intelligence is open to inspection for audit or compliance reviews by the insurance division (division) and the department of health and human services; (8) disclosures pertaining to the use and oversight of the artificial intelligence are contained in written policies and procedures; (9) the artificial intelligence’s performance, use, and outcomes are periodically reviewed and revised; (10) patient data is not used beyond its intended and stated purpose; and (11) the artificial intelligence does not cause harm to a covered person. “Artificial intelligence” is defined in the bill. The artificial intelligence shall not deny, delay, or modify health care services (services) based on medical necessity, and a determination of medical necessity shall be made only by a competent provider. The bill requires a utilization review organization (organization) to respond to a request for prior authorization (authorization) from a provider within 48 hours after receipt for urgent requests or within 10 calendar days for nonurgent requests, unless there are complex or unique circumstances, or the organization is experiencing an unusually high volume of authorization requests, then an organization must respond within 15 calendar days. Within 24 hours after receipt of an authorization request, the organization shall notify a provider of, or make available, a receipt for the authorization request. The bill requires an organization to annually review all services for which authorization is required and to eliminate authorization requirements for services for which authorization requests are so routinely approved that the authorization requirement is not justified as it does not promote health care quality or reduce health care spending. Complaints regarding an organization’s compliance with the bill may be directed to the division, and the division shall notify an organization of all complaints. Complaints received under the bill shall not be considered public records. Under the bill, a carrier that utilizes authorization shall make statistics available regarding authorization approvals and denials on the carrier’s internet site in a readily accessible format. Following each calendar year, the statistics shall be updated annually by March 31, and shall include all of the information detailed in the bill. Under the bill, carriers, hospital and medical service corporations, health maintenance organizations, and providers shall comply with the requirements of Tit. I of the federal No Surprises Act, Pub. L. No. 116-260, Division BB, as may be amended, and the commissioner of insurance (commissioner) shall enforce such compliance. The commissioner may refer cases of noncompliance to the federal department of health and human services under the terms of a collaborative enforcement agreement, or to the attorney general. Under current law, an independent review organization (IRO) required to maintain written records shall submit a report to the commissioner upon request. Under the bill, an IRO required to maintain written records shall annually submit a report to the commissioner. The commissioner shall make the IRO reports publicly accessible on the division’s internet site. Under current law, each carrier required to maintain written records of requests for external review shall submit a report to the commissioner upon request. Under the bill, each carrier required to maintain written records of requests for external review shall annually submit a report to the commissioner. The commissioner shall make the carrier reports publicly accessible on the division’s internet site. The bill requires, on or before January 15, 2026, all carriers that deliver, issue for delivery, continue, or renew a health benefit plan (plan) in this state on or after January 1, 2026, to implement an authorization exemption pilot program (program) that exempts a subset of participating providers, including primary providers, from certain authorization requirements. Each carrier shall make available for each plan details about the plan’s authorization exemption requirements on the carrier’s internet site, including the carrier’s criteria for a provider to qualify for the program, the health care services that are exempt from authorization requirements, the estimated number of providers who are eligible for the program, including the providers’ specialties and the percentage of the providers that are primary care providers, and contact information for consumers and providers to contact the plan about the program or a provider’s eligibility for the program. On or before January 15, 2027, each carrier required to implement a program under the bill shall submit a report to the commissioner containing the results of the program, including an analysis of the costs and savings of the program, the plan’s recommendations for continuing or expanding the program, feedback received by each plan, and an assessment of the administrative costs incurred by each of the carrier’s plans to administer and implement authorization requirements under the program.

AI Summary

Committee Categories

Molly Donahue (D)*,  Janet Petersen (D)*,  Sarah Trone Garriott (D)*,  Zach Wahls (D)*,  Mike Zimmer (D)*, 

Subcommittee: Driscoll, Petersen, and Warme. S.J. 492. (on 03/11/2025)

Official Document