SB 5395

Summary

As enrolled: - Requires that upon a prior authorization determination denial, a carrier must include credentials and other information of the provider who had clinical oversight. Requires disclosure of adjustments to policies and procedures. - Allows only licensed physicians or licensed health professionals to deny prior authorization requests based on medical necessity. - Prohibits artificial intelligence from being the sole basis to deny, delay, or modify care. Allows AI to be used to assist in approvals with required human oversight, but prohibits determinations on group data sets. - Requires equitable application of AI with systems open to audit. - Prohibits a carrier from retrospectively denying coverage, or modifying to a service less intensive than that included in the original request, for care that had prior authorization, unless based on a material representation or coverage is lawfully rescinded, canceled, or terminated retrospectively. - Requires reporting of the total number of prior authorization requests, approvals, and denials.

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