Safeguard Health Ins. Utilization Reviews.

GENERAL ASSEMBLY OF NORTH CAROLINA
SESSION 2025
S 1
SENATE BILL 287

Short Title: Safeguard Health Ins. Utilization Reviews. (Public)
Sponsors: Senator Adcock (Primary Sponsor).
Referred to: Rules and Operations of the Senate
March 17, 2025
*S287-v-1*
A BILL TO BE ENTITLED 1
AN ACT TO ENSURE THA T HEALTH BENEFIT PLA N DETERMINATIONS OF THE 2
MEDICAL NECESSITY OR APPROPRIATENESS OF HEALTHCARE SERVICES 3
CONTINUE TO BE MADE BY LICENSED AND QUAL IFIED HEALTHCARE 4
PROVIDERS. 5
The General Assembly of North Carolina enacts: 6
SECTION 1. G.S. 58-50-61 reads as rewritten: 7
"§ 58-50-61. Utilization review. 8
… 9
(o) Violation. – A In accordance with this Chapter, a violation of this section subjects an 10
insurer and an agent of the insurer to G.S. 58-2-70. 11
(p) Reserved for future codification purposes. 12
(q) Reserved for future codification purposes. 13
(r) Reserved for future codification purposes. 14
(s) Artificial Intelligence. – An insurer shall not use an art ificial intelligence -based 15
algorithm as the sole basis for a utilization review determination to , in whole or in part, deny, 16
delay, or modify any healthcare services for an insured. Only individuals meeting the licensing 17
and qualification requirements for participating in the utilization review process under this 18
section shall make a determination regarding the medical necessity or appropriateness of any 19
healthcare service. Insurers shall verify that all contracts with a third party, including wi th a 20
pharmacy benefits manager, for conducting any utilizat ion review are not in violation of this 21
subsection." 22
SECTION 2. In accordance with G.S. 135-48.24(b) and G.S. 135-48.30(a)(7) which 23
require the State Treasurer to implement procedures that are substantially similar to the 24
provisions of G.S. 58-50-61 for t he North Carolina State Health Plan for Teachers and State 25
Employees (State Health Plan), the State Treasurer and the Executive Administrator of the State 26
Health Plan shall review all practices of the State Health Plan and all contracts with, and practices 27
of, any third party conducting any utilization review on behalf of the State Health Plan to ensure 28
compliance with G.S. 58-50-61(s), as amended by Section 1 of this act. 29
SECTION 3. This act is effective 30 days after it becomes law. 30