New California regulation of health plans’ automated claims processing using modern technology, including AI

Lexology October 7, 2024
Reed Smith LLP

Key takeaways

• California law will impose new obligations on in-state and out-of-state health care service plans (HCSPs) and disability insurers that use automated decision-making tools to analyze medical necessity in utilization reviews affecting California enrollees
• Health care professionals – not automated decision-making tools – may deny, delay, or modify provision of health care based on medical necessity determinations
• Noncompliance may result in civil and criminal penalties

California became one of the first states to enact a law that specifically regulates the use of an “artificial intelligence, algorithm, or other software tool” (automated decision-making tool) by HCSPs and disability insurers to analyze medical necessity in their review or management of requests by health care providers related to the provision...

Today's Sponsors

Today's Sponsor