Binding law — in force
From 2025-01-01, disclosures pertaining to the use and oversight of the artificial intelligence, algorithm or other software tool must be contained in the written utilization-review policies and procedures (H&S 1367.01(k)(1)(H); Ins. 10123.135(j)(1)(H)), which are filed with the regulator and disclosed to providers, enrollees and the public on request ((b)); the tool's criteria and guidelines must comply with the chapter and state and federal law ((C)); and the tool must be open to inspection for audit or compliance reviews by the regulator ((G)), which for plans is reviewed in each onsite medical survey (1367.01(l)). Detect the absence of a written AI-use and oversight policy and an inspection record.
ca-sb1120.ai-policies-disclosure-and-inspection · Cal. Health & Safety Code 1367.01(k)(1)(H) · official source · jurisdictions: US-CA
The guard to add, and how far to trust this rule
Binding law — in force
From 2025-01-01, the plan or insurer must ensure that the use of the artificial intelligence, algorithm or other software tool does not discriminate, directly or indirectly, against enrollees in violation of state or federal law (H&S 1367.01(k)(1)(E); Ins. 10123.135(j)(1)(E)), that the tool is fairly and equitably applied, including under applicable HHS regulations and guidance ((F)), and that its performance, use and outcomes are periodically reviewed and revised to maximize accuracy and reliability ((I)). Detect the absence of a recurring accuracy, outcome and disparity review of the tool.
ca-sb1120.fair-application-and-periodic-review · Cal. Health & Safety Code 1367.01(k)(1)(E) · official source · jurisdictions: US-CA
The guard to add, and how far to trust this rule
Binding law — in force
From 2025-01-01, a plan or disability insurer that uses an artificial intelligence, algorithm or other software tool for utilization review must ensure the tool bases its determination, as applicable, on the enrollee's medical or other clinical history, the individual clinical circumstances presented by the requesting provider and other relevant clinical information in the enrollee's record (H&S 1367.01(k)(1)(A); Ins. 10123.135(j)(1)(A)), and does not base it solely on a group dataset ((k)(1)(B); (j)(1)(B)). Detect utilization-review model calls built without the member's clinical record or the provider's submission.
ca-sb1120.individual-clinical-data-basis · Cal. Health & Safety Code 1367.01(k)(1)(A) · official source · jurisdictions: US-CA
The guard to add, and how far to trust this rule
Binding law — in force
From 2025-01-01, H&S Code 1367.01(k)(2) and Ins. Code 10123.135(j)(2) provide that an artificial intelligence, algorithm or other software tool used for utilization review shall not deny, delay or modify health care services based in whole or in part on medical necessity: a determination of medical necessity is made only by a licensed physician or a licensed health care professional competent to evaluate the specific clinical issues, reviewing the requesting provider's recommendation, the enrollee's medical or clinical history and individual clinical circumstances (and only such a person may deny or modify a request, 1367.01(e), 10123.135(e)). The tool must not supplant health care provider decisionmaking ((k)(1)(D), (j)(1)(D)) or directly or indirectly cause harm to the enrollee ((K)). Detect model or scoring output that sets a denial, delay or modification without a clinical reviewer's decision.
ca-sb1120.licensed-reviewer-decides-medical-necessity · Cal. Health & Safety Code 1367.01(k)(2) · official source · jurisdictions: US-CA
The guard to add, and how far to trust this rule
Binding law — in force
From 2025-01-01, the plan or insurer must ensure that patient data is not used beyond its intended and stated purpose, consistent with the Confidentiality of Medical Information Act and HIPAA, as applicable (H&S 1367.01(k)(1)(J); Ins. 10123.135(j)(1)(J)). Detect utilization-review patient data flowing to model training or fine-tuning, marketing lists or product analytics.
ca-sb1120.patient-data-purpose-limit · Cal. Health & Safety Code 1367.01(k)(1)(J) · official source · jurisdictions: US-CA
The guard to add, and how far to trust this rule
