Binding law — in force
A utilization review agent may not use an automated decision system to make an adverse determination, wholly or partly (Texas SB 815)
Ins. Code 4201.156(a), added by SB 815 (effective 2025-09-01; applies to utilization review for health benefit plans delivered, issued or renewed on or after 2026-01-01, SB 815 sec. 4): a utilization review agent may not use an automated decision system (an algorithm, including one incorporating an artificial intelligence system, that uses data-based analytics to make, suggest or recommend determinations, 4201.002(1-c)) to make, wholly or partly, an adverse determination (a determination that services are not medically necessary or appropriate, or are experimental or investigational). The Commissioner may audit and inspect its use at any time (4201.156(b)); algorithms, AI and automated decision systems may still be used for administrative support or fraud detection (4201.156(c)). Detect automated output that sets an adverse status and prompts or schemas that ask a model to return a denial.
tx-sb815.no-automated-adverse-determination · Tex. Ins. Code 4201.156(a) · official source · jurisdictions: US-TX