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STATE OF OKLAHOMA
2nd Session of the 60th Legislature (2026)
SENATE BILL 1967 By: Mann
AS INTRODUCED
An Act relating to the Hospital and Medical Services
Utilization Review Act; amending 36 O.S. 2021,
Section 6552, which relates to definitions; defining
terms; requiring certain utilization review
organization or insurer that uses certain artificial
intelligence tool to adhere to certain requirements;
prohibiting certain tool to deny, delay, or modify
certain services; requiring certain determinations to
be made by certain licensed professional; requiring
certain health benefit plan to notify certain
enrollees about use of certain tools; requiring
health benefit plan to submit certain tools to the
Insurance Commissioner; requiring Commissioner to
implement certain processes; requiring certain
clinical peer reviewer to document certain
utilization review; providing for certain fines and
fees; requiring Commissioner to promulgate rules and
regulations; providing for codification; and
providing an effective date.
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. AMENDATORY 36 O.S. 2021, Section 6552, is
amended to read as follows:
Section 6552. As used in the Hospital and Medical Services
Utilization Review Act:
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1. “Utilization review” means a system for prospectively,
concurrently and retrospectively reviewing the appropriate and
efficient allocation of hospital resources and medical services
given or proposed to be given to a patient or group of patients. It
does not include an insurer’s normal claim review process to
determine compliance with the specific terms and conditions of the
insurance policy
“Artificial intelligence” means a computer system, program, or
set of algorithms capable of performing tasks on producing outposts
that imitate intelligent human behaviors;
2. “Private review agent” means a person or entity who performs
utilization review on behalf of:
a. an employer in this state, or
b. a third party that provides or administers hospital
and medical benefits to citizens of this state,
including, but not limited to:
(1) a health maintenance organization issued a
license pursuant to Section 2501 et seq. of Title
63 of the Oklahoma Statutes, unless the health
maintenance organization is federally regulated
and licensed and has on file with the Insurance
Commissioner a plan of utilization review carried
out by health care professionals and providing
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for complaint and appellate procedures for
claims, or
(2) a health insurer, not-for-profit hospital service
or medical plan, health insurance service
organization, or preferred provider organization
or other entity offering health insurance
policies, contracts or benefits in this state
“Artificial intelligence tool” means a tool that uses an
artificial intelligence or algorithm for the purpose of utilization
review based in whole or in part on medical necessity;
3. “Utilization review plan” means a description of utilization
review procedures;
4. “Commissioner” means the Insurance Commissioner;
5. 4. “Certificate” means a certificate of registration granted
by the Insurance Commissioner to a private review agent; and
6. 5. “Health care provider” means any person, firm,
corporation or other legal entity that is licensed, certified, or
otherwise authorized by the laws of this state to provide health
care services, procedures or supplies in the ordinary course of
business or practice of a profession;
6. “Private review agent” means a person or entity that
performs utilization review on behalf of:
a. an employer in this state, or
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b. a third party that provides or administers hospital
and medical benefits to citizens of this state,
including, but not limited to:
(1) a health maintenance organization issued a
license pursuant to Section 6901 et seq. of this
title, unless the health maintenance organization
is federally regulated and licensed and has on
file with the Insurance Commissioner a plan of
utilization review carried out by health care
professionals and providing for complaint and
appellate procedures for claims, or
(2) a health insurer, not-for-profit hospital service
or medical plan, health insurance service
organization, or preferred provider organization
or other entity offering health insurance
policies, contracts or benefits in this state;
7. “Utilization review” means a system for prospectively,
concurrently, and retrospectively reviewing the allocation of
hospital resources and medical services given or proposed to be
given to a patient or group of patients. It does not include an
insurer’s normal claim review process to determine compliance with
the specific terms and conditions of the insurance policy;
8. “Utilization review plan” means a description of utilization
review procedures; and
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9. “Utilization review organization” means the same as defined
in Section 6475.3 of this title.
SECTION 2. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6567 of Title 36, unless there
is created a duplication in numbering, reads as follows:
A. A utilization review organization, disability insurer, or
specialized health insurer that uses an artificial intelligence tool
or contracts with or otherwise works through an entity that uses an
artificial intelligence tool shall ensure that the artificial
intelligence tool:
1. Bases its determination on the following information, as
applicable:
a. an enrollee’s medical or other clinical history,
b. individual clinical circumstances as presented by the
requesting provider, and
c. other relevant clinical information contained in the
enrollee’s medical or other clinical record;
2. Does not base its determination solely on a group dataset;
3. Does not supplant health care provider decision-making;
4. Does not discriminate against enrollees in violation of
state and federal law;
5. Does not use patient data beyond its intended and stated
purpose consistent with the federal Health Insurance Portability and
Accountability Act of 1996, P.L. No. 104-191, as applicable;
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6. Does not cause harm to the enrollee;
7. Is applied in accordance with any applicable regulations and
guidance issued by the federal Department of Health and Human
Services;
8. Is open to inspection for audit or compliance review by the
Insurance Commissioner;
9. Contains disclosures pertaining to the use and oversight of
the artificial intelligence tool in the written policies and
procedures; and
10. Requires performance use and outcomes to be periodically
reviewed and revised to maximize accuracy and reliability.
B. The artificial intelligence tool shall not deny, delay, or
modify health care services based, in whole or in part, on medical
necessity. A determination of medical necessity shall be made only
by a licensed physician or a licensed health care professional
competent to evaluate the specific clinical issues involved in the
health care services requested by the provider, by reviewing and
considering the requesting provider’s recommendation, the enrollee’s
medical or other clinical history, and individual circumstances.
C. Any health benefit plan in this state shall notify enrollees
and insureds about the use or lack of use of artificial intelligence
tools in the utilization review process on the accessible Internet
website of such health benefit plan.
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D. A clinical peer reviewer who participates in a utilization
review process for a health benefit plan that initially uses
artificial intelligence tools for a utilization review shall open
and document the utilization review of the individual clinical
records or data prior to issuing an adverse determination.
E. A violation of this act by a health benefit plan or clinical
peer reviewer shall be subject to one or more of the following
penalties, not to exceed in aggregate Five Hundred Thousand Dollars
($500,000.00) for a health benefit plan or One Hundred Thousand
Dollars ($100,000.00) for a clinical peer reviewer, in a calendar
year:
1. Suspension or revocation of a license;
2. Refusal, for a period not to exceed one (1) year, to issue a
new license; or
3. A fine not more than Ten Thousand Dollars ($10,000.00) for
each willful violation.
F. Penalties pursuant to this act shall be in addition to any
other remedies or penalties that may be imposed under any other
applicable state or federal law.
G. This act shall apply to utilization review or utilization
management functions that prospectively, concurrently,
retrospectively review requests for covered health care services.
H. The Commissioner may promulgate rules and regulations
pursuant to the provisions of this act.
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SECTION 3. This act shall become effective November 1, 2026.
60-2-2293 CAD 1/15/2026 9:15:11 AM