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Senate
File
562
-
Introduced
SENATE
FILE
562
BY
TRONE
GARRIOTT
,
DONAHUE
,
PETERSEN
,
ZIMMER
,
and
WAHLS
A
BILL
FOR
An
Act
relating
to
utilization
review
organizations,
prior
1
authorizations
and
exemptions,
medical
billing,
and
2
independent
review
organizations.
3
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
4
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Section
1.
NEW
SECTION
.
514F.2A
Utilization
review
——
use
1
of
artificial
intelligence.
2
1.
For
the
purposes
of
this
section:
3
a.
“Artificial
intelligence”
means
an
engineered
or
4
machine-based
system
that
varies
in
its
level
of
autonomy
and
5
that
can,
for
explicit
or
implicit
objectives,
infer
from
the
6
input
the
system
receives
how
to
generate
outputs
that
can
7
influence
physical
or
virtual
environments.
8
b.
“Covered
person”
means
the
same
as
defined
in
section
9
51F.8.
10
c.
“Health
care
provider”
means
the
same
as
defined
in
11
section
514F.8.
12
d.
“Health
carrier”
means
the
same
as
defined
in
section
13
514F.8.
14
e.
“Utilization
review”
means
the
same
as
defined
in
section
15
514F.7.
16
2.
A
health
carrier
that
uses
artificial
intelligence,
17
an
algorithm,
or
other
software
tool
for
the
purpose
of
18
utilization
review,
based
in
whole
or
in
part
on
medical
19
necessity,
or
that
contracts
with
or
otherwise
works
through
20
an
entity
that
uses
artificial
intelligence,
an
algorithm,
or
21
other
software
tool
for
the
purpose
of
utilization
review,
22
based
in
whole
or
in
part
on
medical
necessity,
shall
ensure
23
all
of
the
following:
24
a.
The
artificial
intelligence,
algorithm,
or
other
software
25
tool
bases
its
determination
on
the
following
information,
as
26
applicable:
27
(1)
A
covered
person’s
medical
or
other
clinical
history.
28
(2)
Individual
clinical
circumstances
as
presented
by
the
29
requesting
health
care
provider.
30
(3)
Other
relevant
clinical
information
contained
in
the
31
covered
person’s
medical
or
other
clinical
record.
32
b.
The
artificial
intelligence,
algorithm,
or
other
software
33
tool’s
criteria
and
guidelines
comply
with
this
chapter
and
34
applicable
state
and
federal
law.
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c.
The
artificial
intelligence,
algorithm,
or
other
software
1
tool
does
not
supplant
health
care
provider
decision
making.
2
d.
The
use
of
the
artificial
intelligence,
algorithm,
3
or
other
software
tool
does
not
discriminate,
directly
or
4
indirectly,
against
covered
persons
in
violation
of
state
or
5
federal
law.
6
e.
The
artificial
intelligence,
algorithm,
or
other
software
7
tool
is
fairly
and
equitably
applied,
including
in
accordance
8
with
any
applicable
regulations
and
guidance
issued
by
the
9
federal
department
of
health
and
human
services.
10
f.
The
artificial
intelligence,
algorithm,
or
other
software
11
tool
is
open
to
inspection
for
audit
or
compliance
reviews
by
12
the
division
and
the
department
of
health
and
human
services
13
pursuant
to
applicable
state
and
federal
law.
14
g.
Disclosures
pertaining
to
the
use
and
oversight
of
the
15
artificial
intelligence,
algorithm,
or
other
software
tool
are
16
contained
in
written
policies
and
procedures
maintained
by
the
17
health
carrier.
18
h.
The
artificial
intelligence,
algorithm,
or
other
software
19
tool’s
performance,
use,
and
outcomes
are
periodically
reviewed
20
and
revised
to
maximize
accuracy
and
reliability.
21
i.
Patient
data
is
not
used
beyond
its
intended
and
22
stated
purpose,
consistent
with
the
federal
Health
Insurance
23
Portability
and
Accountability
Act
of
1996,
Pub.
L.
No.
24
104-191.
25
j.
The
artificial
intelligence,
algorithm,
or
other
software
26
tool
does
not
directly
or
indirectly
cause
harm
to
a
covered
27
person.
28
3.
Notwithstanding
subsection
2,
the
artificial
29
intelligence,
algorithm,
or
other
software
tool
shall
not
30
deny,
delay,
or
modify
health
care
services
based,
in
whole
31
or
in
part,
on
medical
necessity.
A
determination
of
medical
32
necessity
shall
be
made
only
by
a
health
care
provider
33
competent
to
evaluate
the
specific
clinical
issues
involved
34
in
the
health
care
services
requested
by
the
health
care
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provider
by
reviewing
and
considering
the
requesting
health
1
care
provider’s
recommendation,
the
covered
person’s
medical
or
2
other
clinical
history,
as
applicable,
and
individual
clinical
3
circumstances.
4
Sec.
2.
Section
514F.8,
Code
2025,
is
amended
by
adding
the
5
following
new
subsections:
6
NEW
SUBSECTION
.
1A.
a.
A
utilization
review
organization
7
shall
respond
to
a
request
for
prior
authorization
from
a
8
health
care
provider
as
follows:
9
(1)
Within
forty-eight
hours
after
receipt
for
urgent
10
requests.
11
(2)
Within
ten
calendar
days
after
receipt
for
nonurgent
12
requests.
13
(3)
Within
fifteen
calendar
days
after
receipt
for
14
nonurgent
requests
if
there
are
complex
or
unique
circumstances
15
or
the
utilization
review
organization
is
experiencing
an
16
unusually
high
volume
of
prior
authorization
requests.
17
b.
Within
twenty-four
hours
after
receipt
of
a
prior
18
authorization
request,
the
utilization
review
organization
19
shall
notify
the
health
care
provider
of,
or
make
available
to
20
the
health
care
provider,
a
receipt
for
the
request
for
prior
21
authorization.
22
NEW
SUBSECTION
.
2A.
A
utilization
review
organization
23
shall,
at
least
annually,
review
all
health
care
services
for
24
which
the
health
benefit
plan
requires
prior
authorization
and
25
shall
eliminate
prior
authorization
requirements
for
health
26
care
services
for
which
prior
authorization
requests
are
27
routinely
approved
with
such
frequency
as
to
demonstrate
that
28
the
prior
authorization
requirement
does
not
promote
health
29
care
quality,
or
reduce
health
care
spending,
to
a
degree
30
sufficient
to
justify
the
health
benefit
plan’s
administrative
31
costs
to
require
the
prior
authorization.
32
NEW
SUBSECTION
.
3A.
Complaints
regarding
a
utilization
33
review
organization’s
compliance
with
this
chapter
may
be
34
directed
to
the
insurance
division.
The
insurance
division
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shall
notify
a
utilization
review
organization
of
all
1
complaints
regarding
the
utilization
review
organization’s
2
noncompliance
with
this
chapter.
All
complaints
received
3
pursuant
to
this
subsection
shall
not
be
considered
public
4
records
for
purposes
of
chapter
22.
5
Sec.
3.
NEW
SECTION
.
514F.8A
Prior
authorizations
——
6
statistics.
7
1.
For
purposes
of
this
section:
8
a.
“Covered
person”
means
the
same
as
defined
in
section
9
514F.8.
10
b.
“Health
benefit
plan”
means
the
same
as
defined
in
11
section
514J.102.
12
c.
“Health
care
provider”
means
the
same
as
defined
in
13
section
514F.8.
14
d.
“Health
care
services”
means
the
same
as
defined
in
15
514F.8.
16
e.
“Health
carrier”
means
the
same
as
defined
in
514F.8.
17
f.
“Prior
authorization”
means
the
same
as
defined
in
18
514F.8.
19
g.
“Utilization
review”
means
the
same
as
defined
in
section
20
514F.7.
21
h.
“Utilization
review
organization”
means
the
same
as
22
defined
in
514F.8.
23
2.
A
health
carrier
that
utilizes
prior
authorization
24
shall
make
statistics
available
regarding
prior
authorization
25
approvals
and
denials
on
the
health
carrier’s
internet
site
26
in
a
readily
accessible
format.
Following
each
immediately
27
preceding
calendar
year,
the
statistics
shall
be
updated
28
annually
by
March
31,
and
shall
include
all
of
the
following
29
information:
30
a.
A
list
of
all
health
care
services,
including
31
medications,
that
are
subject
to
prior
authorization.
32
b.
The
percentage
of
standard
prior
authorization
requests
33
that
were
approved,
aggregated
for
all
items
and
services.
34
c.
The
percentage
of
standard
prior
authorization
requests
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that
were
denied,
aggregated
for
all
items
and
services.
1
d.
The
percentage
of
prior
authorization
requests
that
were
2
approved
after
appeal,
aggregated
for
all
items
and
services.
3
e.
The
percentage
of
prior
authorization
requests
for
which
4
the
time
frame
for
review
was
extended,
and
the
request
was
5
approved,
aggregated
for
all
items
and
services.
6
f.
The
percentage
of
expedited
prior
authorization
requests
7
that
were
approved,
aggregated
for
all
items
and
services.
8
g.
The
percentage
of
expedited
prior
authorization
requests
9
that
were
denied,
aggregated
for
all
items
and
services.
10
h.
The
average
and
median
time
that
elapsed
between
the
11
submission
of
a
request
and
a
determination
by
the
health
12
carrier
or
utilization
review
organization,
for
standard
prior
13
authorization,
aggregated
for
all
items
and
services.
14
i.
The
average
and
median
time
that
elapsed
between
the
15
submission
of
a
request
and
a
decision
by
the
health
carrier
16
or
utilization
review
organization
for
expedited
prior
17
authorizations,
aggregated
for
all
items
and
services.
18
j.
Any
other
information
the
division
determines
19
appropriate.
20
Sec.
4.
NEW
SECTION
.
514F.10
Medical
billing.
21
1.
For
purposes
of
this
section:
22
a.
“Commissioner”
means
the
commissioner
of
insurance.
23
b.
“Health
care
provider”
means
the
same
as
defined
in
24
section
514F.8.
25
c.
“Health
carrier”
means
the
same
as
defined
in
section
26
514F.9.
27
d.
“Health
maintenance
organization”
means
health
28
maintenance
organization
as
defined
in
section
514B.1.
29
2.
Health
carriers,
hospital
and
medical
service
30
corporations,
health
maintenance
organizations,
and
health
care
31
providers
shall
comply
with
the
requirements
of
Tit.
I
of
the
32
federal
No
Surprises
Act,
Pub.
L.
No.
116-260,
Division
BB,
as
33
amended.
34
3.
The
commissioner
shall
enforce
this
section
to
the
extent
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permitted
under
state
and
federal
law.
The
commissioner
may
1
refer
cases
of
noncompliance
to
the
federal
department
of
2
health
and
human
services
under
the
terms
of
a
collaborative
3
enforcement
agreement,
or
to
the
attorney
general.
4
Sec.
5.
Section
514J.114,
subsection
1,
paragraph
b,
5
unnumbered
paragraph
1,
Code
2025,
is
amended
to
read
as
6
follows:
7
Each
independent
review
organization
required
to
maintain
8
written
records
pursuant
to
this
section
shall
annually
submit
9
to
the
commissioner
,
upon
request,
a
report
in
the
format
10
specified
by
the
commissioner.
The
report
shall
include
in
the
11
aggregate
by
state
and
by
health
carrier
all
of
the
following:
12
Sec.
6.
Section
514J.114,
subsection
1,
Code
2025,
is
13
amended
by
adding
the
following
new
paragraph:
14
NEW
PARAGRAPH
.
d.
The
commissioner
shall
make
the
15
independent
review
organization
reports
required
under
this
16
subsection
publicly
accessible
on
the
division’s
internet
site.
17
Sec.
7.
Section
514J.114,
subsection
2,
paragraph
b,
18
unnumbered
paragraph
1,
Code
2025,
is
amended
to
read
as
19
follows:
20
Each
health
carrier
required
to
maintain
written
records
of
21
requests
for
external
review
pursuant
to
this
subsection
shall
22
annually
submit
to
the
commissioner
,
upon
request,
a
report
in
23
the
format
specified
by
the
commissioner.
The
report
shall
24
include
in
the
aggregate
by
state
and
by
type
of
health
benefit
25
plan
offered
all
of
the
following:
26
Sec.
8.
Section
514J.114,
subsection
2,
Code
2025,
is
27
amended
by
adding
the
following
new
paragraph:
28
NEW
PARAGRAPH
.
d.
The
commissioner
shall
make
the
health
29
carrier
reports
required
under
this
subsection
publicly
30
accessible
on
the
division’s
internet
site.
31
Sec.
9.
PRIOR
AUTHORIZATION
EXEMPTION
PROGRAM.
32
1.
On
or
before
January
15,
2026,
all
health
carriers
33
that
deliver,
issue
for
delivery,
continue,
or
renew
a
health
34
benefit
plan
in
this
state
on
or
after
January
1,
2026,
and
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that
require
prior
authorizations,
shall
implement
a
pilot
1
program
that
exempts
a
subset
of
participating
health
care
2
providers,
at
least
some
of
whom
shall
be
primary
health
care
3
providers,
from
certain
prior
authorization
requirements.
4
2.
Each
health
carrier
shall
make
available
on
the
health
5
carrier’s
internet
site
for
each
health
benefit
plan
that
the
6
health
carrier
delivers,
issues
for
delivery,
continues,
or
7
renews
in
this
state,
details
about
the
health
benefit
plan’s
8
prior
authorization
exemption
program,
including
all
of
the
9
following
information:
10
a.
The
health
carrier’s
criteria
for
a
health
care
provider
11
to
qualify
for
the
exemption
program.
12
b.
The
health
care
services
that
are
exempt
from
prior
13
authorization
requirements
for
health
care
providers
who
14
qualify
under
paragraph
“a”.
15
c.
The
estimated
number
of
health
care
providers
who
are
16
eligible
for
the
program,
including
the
health
care
providers’
17
specialties,
and
the
percentage
of
the
health
care
providers
18
that
are
primary
care
providers.
19
d.
Contact
information
for
the
health
benefit
plan
for
20
consumers
and
health
care
providers
to
contact
the
health
21
benefit
plan
about
the
exemption
program,
or
about
a
health
22
care
provider’s
eligibility
for
the
exemption
program.
23
3.
On
or
before
January
15,
2027,
each
health
carrier
24
required
to
implement
a
prior
authorization
exemption
25
program
pursuant
to
subsection
1
shall
submit
a
report
to
the
26
commissioner
of
insurance
that
contains
all
of
the
following:
27
a.
The
results
of
the
exemption
program,
including
an
28
analysis
of
the
costs
and
savings
of
the
exemption
program.
29
b.
The
health
benefit
plan’s
recommendations
for
continuing
30
or
expanding
the
exemption
program.
31
c.
Feedback
received
by
each
health
benefit
plan
from
32
health
care
providers
and
other
interested
parties
regarding
33
the
exemption
program.
34
d.
An
assessment
of
the
administrative
costs
incurred
by
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each
of
the
health
carrier’s
health
benefit
plans
to
administer
1
and
implement
prior
authorization
requirements
under
the
2
exemption
program.
3
EXPLANATION
4
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
5
the
explanation’s
substance
by
the
members
of
the
general
assembly.
6
This
bill
relates
to
utilization
review
organizations,
prior
7
authorizations
and
exemptions,
medical
billing,
and
independent
8
review
organizations.
9
Under
the
bill,
a
health
carrier
(carrier)
that
uses
an
10
artificial
intelligence,
algorithm,
or
other
software
tool
11
(artificial
intelligence)
for
the
purpose
of
utilization
12
review,
or
that
contracts
with
or
works
through
an
entity
that
13
uses
an
artificial
intelligence
for
the
purpose
of
utilization
14
review,
shall
ensure
that
(1)
the
artificial
intelligence
15
bases
its
determination
on
the
information
described
in
16
the
bill;
(2)
the
artificial
intelligence
does
not
base
its
17
determination
solely
on
a
group
dataset;
(3)
the
artificial
18
intelligence’s
criteria
and
guidelines
comply
with
Code
19
chapter
514F
and
applicable
state
and
federal
law;
(4)
the
20
artificial
intelligence
does
not
supplant
health
care
provider
21
(provider)
decision
making;
(5)
the
use
of
the
artificial
22
intelligence
does
not
discriminate
against
covered
persons;
23
(6)
the
artificial
intelligence
is
fairly
and
equitably
24
applied;
(7)
the
artificial
intelligence
is
open
to
inspection
25
for
audit
or
compliance
reviews
by
the
insurance
division
26
(division)
and
the
department
of
health
and
human
services;
27
(8)
disclosures
pertaining
to
the
use
and
oversight
of
the
28
artificial
intelligence
are
contained
in
written
policies
and
29
procedures;
(9)
the
artificial
intelligence’s
performance,
30
use,
and
outcomes
are
periodically
reviewed
and
revised;
31
(10)
patient
data
is
not
used
beyond
its
intended
and
stated
32
purpose;
and
(11)
the
artificial
intelligence
does
not
cause
33
harm
to
a
covered
person.
“Artificial
intelligence”
is
defined
34
in
the
bill.
The
artificial
intelligence
shall
not
deny,
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delay,
or
modify
health
care
services
(services)
based
on
1
medical
necessity,
and
a
determination
of
medical
necessity
2
shall
be
made
only
by
a
competent
provider.
3
The
bill
requires
a
utilization
review
organization
4
(organization)
to
respond
to
a
request
for
prior
authorization
5
(authorization)
from
a
provider
within
48
hours
after
receipt
6
for
urgent
requests
or
within
10
calendar
days
for
nonurgent
7
requests,
unless
there
are
complex
or
unique
circumstances,
8
or
the
organization
is
experiencing
an
unusually
high
volume
9
of
authorization
requests,
then
an
organization
must
respond
10
within
15
calendar
days.
Within
24
hours
after
receipt
of
an
11
authorization
request,
the
organization
shall
notify
a
provider
12
of,
or
make
available,
a
receipt
for
the
authorization
request.
13
The
bill
requires
an
organization
to
annually
review
all
14
services
for
which
authorization
is
required
and
to
eliminate
15
authorization
requirements
for
services
for
which
authorization
16
requests
are
so
routinely
approved
that
the
authorization
17
requirement
is
not
justified
as
it
does
not
promote
health
care
18
quality
or
reduce
health
care
spending.
Complaints
regarding
19
an
organization’s
compliance
with
the
bill
may
be
directed
to
20
the
division,
and
the
division
shall
notify
an
organization
of
21
all
complaints.
Complaints
received
under
the
bill
shall
not
22
be
considered
public
records.
23
Under
the
bill,
a
carrier
that
utilizes
authorization
shall
24
make
statistics
available
regarding
authorization
approvals
and
25
denials
on
the
carrier’s
internet
site
in
a
readily
accessible
26
format.
Following
each
calendar
year,
the
statistics
shall
27
be
updated
annually
by
March
31,
and
shall
include
all
of
the
28
information
detailed
in
the
bill.
29
Under
the
bill,
carriers,
hospital
and
medical
service
30
corporations,
health
maintenance
organizations,
and
providers
31
shall
comply
with
the
requirements
of
Tit.
I
of
the
federal
32
No
Surprises
Act,
Pub.
L.
No.
116-260,
Division
BB,
as
may
33
be
amended,
and
the
commissioner
of
insurance
(commissioner)
34
shall
enforce
such
compliance.
The
commissioner
may
refer
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cases
of
noncompliance
to
the
federal
department
of
health
and
1
human
services
under
the
terms
of
a
collaborative
enforcement
2
agreement,
or
to
the
attorney
general.
3
Under
current
law,
an
independent
review
organization
(IRO)
4
required
to
maintain
written
records
shall
submit
a
report
to
5
the
commissioner
upon
request.
Under
the
bill,
an
IRO
required
6
to
maintain
written
records
shall
annually
submit
a
report
to
7
the
commissioner.
The
commissioner
shall
make
the
IRO
reports
8
publicly
accessible
on
the
division’s
internet
site.
9
Under
current
law,
each
carrier
required
to
maintain
written
10
records
of
requests
for
external
review
shall
submit
a
report
11
to
the
commissioner
upon
request.
Under
the
bill,
each
carrier
12
required
to
maintain
written
records
of
requests
for
external
13
review
shall
annually
submit
a
report
to
the
commissioner.
The
14
commissioner
shall
make
the
carrier
reports
publicly
accessible
15
on
the
division’s
internet
site.
16
The
bill
requires,
on
or
before
January
15,
2026,
all
17
carriers
that
deliver,
issue
for
delivery,
continue,
or
renew
a
18
health
benefit
plan
(plan)
in
this
state
on
or
after
January
19
1,
2026,
to
implement
an
authorization
exemption
pilot
program
20
(program)
that
exempts
a
subset
of
participating
providers,
21
including
primary
providers,
from
certain
authorization
22
requirements.
Each
carrier
shall
make
available
for
each
plan
23
details
about
the
plan’s
authorization
exemption
requirements
24
on
the
carrier’s
internet
site,
including
the
carrier’s
25
criteria
for
a
provider
to
qualify
for
the
program,
the
health
26
care
services
that
are
exempt
from
authorization
requirements,
27
the
estimated
number
of
providers
who
are
eligible
for
28
the
program,
including
the
providers’
specialties
and
the
29
percentage
of
the
providers
that
are
primary
care
providers,
30
and
contact
information
for
consumers
and
providers
to
contact
31
the
plan
about
the
program
or
a
provider’s
eligibility
for
the
32
program.
On
or
before
January
15,
2027,
each
carrier
required
33
to
implement
a
program
under
the
bill
shall
submit
a
report
34
to
the
commissioner
containing
the
results
of
the
program,
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including
an
analysis
of
the
costs
and
savings
of
the
program,
1
the
plan’s
recommendations
for
continuing
or
expanding
the
2
program,
feedback
received
by
each
plan,
and
an
assessment
of
3
the
administrative
costs
incurred
by
each
of
the
carrier’s
4
plans
to
administer
and
implement
authorization
requirements
5
under
the
program.
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