In Texas, utilization review agents may use an AI tool for administrative support or fraud-detection functions. However, agents cannot use AI to make adverse determinations.
In Maryland, carriers using AI in utilization reviews must ensure that the AI tool does not supplant the role of health care providers in medical necessity decisions, among other prohibitions. Also, carriers using AI in utilization reviews must ensure that the tool does not delay or modify health care services or harm an enrollee.
Maryland will also require carriers filing utilization plans to include information on how the AI tool will be used. They must also ensure that the performance, use, and outcomes of an AI tool are reviewed and revised at least quarterly.
To ensure compliance with these new laws, both Maryland and Texas state insurance departments may audit and inspect a company’s AI tools.
To learn more about the Maryland and Texas AI measures, along with more than 15 other utilization review laws enacted and regulations adopted recently, access the real-time statutory/regulatory updates in the “Utilization Review Guide,” an electronic 51-state compilation of utilization review statutes, regulations, and forms, at https://payhip.com/b/vsbKo, under the “Subscriptions” tab.
The UR Guide covers the following topics:
- Utilization Review Agent Duties
- Application/Certification Requirements
- Grounds for Certification Denials
- Notice of Change Requirements
- Recordkeeping and Reporting Requirements
- Renewal Requirements
- Confidentiality Requirements
- Complaints
- Exemption Criteria
- Prohibitions
- Waivers
- Deadlines
- Penalties
- Appeal Procedures
The real-time statutory/regulatory updates are only available to subscribers on a yearly plan. However no real-time updates are provided to one-time e-book purchasers, although they may purchase real-time updates separately and later.
About Croneal Consulting Group
Croneal Consulting Group is an information and research services firm that provides publications, database development services, and Web portals for members of the legal, regulatory, and government communities. Besides UST Reports, an insurance bulletin reporting service for five United States territories (American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and the Virgin Islands), the firm counts as its flagship product, InsuranceBulletins.com, an Insurance Bulletin Alert Tracking System, with more than 10,000 insurance bulletins released from 51 state insurance departments from 2006 to the current date.
For CCG’s products and services, visit these sites:
http://www.payhip.com/ccg
http://www.insurancebulletins.com
http://www.cronealconsultinggroup.com
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Source: Croneal Consulting Group
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