Text to be removed highlighted in red.
1 New Subparagraph; Managed Care Law; Utilization Review; Standards and Procedures for Use of Artificial Intelligence. Amend RSA 420-J:6, I by inserting after subparagraph (d) the following new subparagraph:
(e) Each health carrier shall maintain written records related to the health carrier's use of algorithms, artificial intelligence, or other machine based systems, including but not limited to:
(1) Which functions artificial intelligence is used for; and
(2) Protocols ensuring qualified human review of determinations affecting provider coding decisions.
2 New Paragraph; Managed Care Law; Utilization Review; Adverse Determinations; Contracting Liability. Amend RSA 420-J:6 by inserting after paragraph XI the following new paragraphs:
XII. Adverse Determinations.
(a) All adverse determinations, including payment reductions and down coding, must be made by a qualified health care provider.
(b) The health carrier must provide written notice of the adverse determination to the covered person and the covered person's health care provider detailing the reason for the decision.
(c) The health carrier shall maintain records including, but not limited to the following:
(1) The information submitted to the health carrier;
(2) The information reviewed by the qualified health care provider;
(3) Applicable clinical guidelines;
(4) Whether artificial intelligence was used to assist the reviewer; nd
(5) The clinical rationale for the decision.
XIII. Whenever a health carrier contracts to have another entity perform any functions, including use of artificial intelligence systems developed by another entity, related to utilization review, the commissioner shall hold the health carrier responsible for monitoring the activities of the entity with which it contracts and for ensuring that the requirements of this section and applicable rules are met.
3 Effective Date. This act shall take effect January 1, 2027.
Text to be added highlighted in green.
1 New Subparagraph; Managed Care Law; Utilization Review; Standards and Procedures for Use of Artificial Intelligence. Amend RSA 420-J:6, I by inserting after subparagraph (d) the following new subparagraph:
(e) Each health carrier shall maintain written records related to the health carrier's use of algorithms, artificial intelligence, or other machine based systems, including but not limited to:
(1) Which functions artificial intelligence is used for; and
(2) Protocols ensuring qualified human review of determinations affecting provider coding decisions.
2 New Paragraph; Managed Care Law; Utilization Review; Adverse Determinations; Contracting Liability. Amend RSA 420-J:6 by inserting after paragraph XI the following new paragraphs:
XII. Adverse Determinations.
(a) All adverse determinations, including payment reductions and down coding, must be made by a qualified health care provider.
(b) The health carrier must provide written notice of the adverse determination to the covered person and the covered person's health care provider detailing the reason for the decision.
(c) The health carrier shall maintain records including, but not limited to the following:
(1) The information submitted to the health carrier;
(2) The information reviewed by the qualified health care provider;
(3) Applicable clinical guidelines;
(4) Whether artificial intelligence was used to assist the reviewer; nd
(5) The clinical rationale for the decision.
XIII. Whenever a health carrier contracts to have another entity perform any functions, including use of artificial intelligence systems developed by another entity, related to utilization review, the commissioner shall hold the health carrier responsible for monitoring the activities of the entity with which it contracts and for ensuring that the requirements of this section and applicable rules are met.
3 Effective Date. This act shall take effect January 1, 2027.