Binding law — in force
From 2025-10-01, an entity subject to Ins. 15-10B-05.1 must ensure that the artificial intelligence, algorithm or other software tool bases its determinations on the enrollee's medical or other clinical history, individual clinical circumstances as presented by a requesting provider, or other relevant clinical information in the enrollee's record ((c)(1)), and does not base its determinations solely on a group dataset ((c)(2)). Detect utilization-review model calls built without the member's clinical record or the provider's submission.
md-hb820.individual-clinical-data-basis · Md. Code, Ins. 15-10B-05.1(c)(1) · official source · jurisdictions: US-MD
The guard to add, and how far to trust this rule
Binding law — in force
From 2025-10-01, an artificial intelligence, algorithm or other software tool may not deny, delay or modify health care services (Ins. 15-10B-05.1(d)), and the entity must ensure that it does not replace the role of a health care provider in the determination process under 15-10B-07 ((c)(4)), under which all adverse decisions are made by a licensed physician, or a panel of health care service reviewers with at least one physician, board certified or eligible in the same specialty and knowledgeable about the service (dentists for dental services; 15-10B-07(a)), not compensated in a way that deters appropriate care ((b)); and that the tool does not directly or indirectly cause harm to an enrollee ((c)(11)). Detect automated output that sets a denial, delay or modification without a physician's decision.
md-hb820.no-ai-denial-provider-decides · Md. Code, Ins. 15-10B-05.1(d) · official source · jurisdictions: US-MD
The guard to add, and how far to trust this rule
Binding law — in force
From 2025-10-01, the entity must ensure that patient data is not used beyond its intended and stated purpose, consistent with HIPAA, as applicable (Ins. 15-10B-05.1(c)(10)). Detect utilization-review patient data flowing to model training or fine-tuning, marketing lists or product analytics.
md-hb820.patient-data-purpose-limit · Md. Code, Ins. 15-10B-05.1(c)(10) · official source · jurisdictions: US-MD
The guard to add, and how far to trust this rule
Binding law — in force
From 2025-10-01, the entity must ensure that the use of the artificial intelligence, algorithm or other software tool does not result in unfair discrimination (Ins. 15-10B-05.1(c)(5)), that it is fairly and equitably applied, including under applicable HHS regulations and guidance ((c)(6)), and that its performance, use and outcomes are reviewed and revised, if necessary and at least on a quarterly basis, to maximize accuracy and reliability ((c)(9)). Detect the absence of a quarterly accuracy, outcome and disparity review.
md-hb820.quarterly-accuracy-and-fairness-review · Md. Code, Ins. 15-10B-05.1(c)(5) · official source · jurisdictions: US-MD
The guard to add, and how far to trust this rule
Binding law — in force
From 2025-10-01, each carrier's quarterly report to the Commissioner (on the Commissioner's form, aggregated by zip code as required) must describe the number of adverse decisions it issued under 15-10A-02(f), whether each involved a prior authorization or step therapy protocol, the type of service, and whether an artificial intelligence, algorithm or other software tool was used in making the adverse decision (Ins. 15-10A-06(a)(1)(iii)6, as added by Chapter 747). Detect adverse decisions recorded from a model or scoring call with no field recording AI use, and no quarterly report job.
md-hb820.quarterly-report-ai-use-in-adverse-decisions · Md. Code, Ins. 15-10A-06(a)(1) · official source · jurisdictions: US-MD
The guard to add, and how far to trust this rule
Binding law — in force
From 2025-10-01, the entity must ensure that written policies and procedures, including how the artificial intelligence, algorithm or other software tool will be used and what oversight will be provided, are included in the utilization plan submitted under 15-10B-05 (Ins. 15-10B-05.1(c)(8)), that the criteria and guidelines for using the tool comply with the title ((c)(3)), and that the tool is open to inspection for audit or compliance reviews by the Commissioner ((c)(7)). Detect the absence of an AI-use and oversight policy in the utilization plan and an inspection record.
md-hb820.utilization-plan-ai-policies-and-inspection · Md. Code, Ins. 15-10B-05.1(c)(8) · official source · jurisdictions: US-MD
The guard to add, and how far to trust this rule
