THE BILL ITSELF
CS/CS/HB 527
Mandatory Human Reviews of Insurance Claim Denials
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A bill to be entitled
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An act relating to mandatory human reviews of
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insurance claim denials; creating s. 440.131, F.S.;
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defining terms; authorizing workers' compensation
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carriers to use artificial intelligence systems and
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machine learning systems to assist in processing
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claims; prohibiting the use of artificial intelligence
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or machine learning systems as the sole basis for
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determining whether to reduce a claim payment or deny
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a claim or portion of a claim; requiring that
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carriers' decisions to deny a claim or portion of a
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claim or reduce a claim be made by qualified human
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professionals; specifying the duties of qualified
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human professionals; requiring a carrier to maintain
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certain records; requiring carriers to include certain
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information in denial communications to claimants;
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requiring that certain carriers detail certain
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information in their claims-handling manual;
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authorizing the Department of Financial Services to
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conduct examinations and investigations under certain
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circumstances and to adopt rules; providing penalties;
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creating s. 627.4263, F.S.; defining terms;
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authorizing insurers to use artificial intelligence
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systems and machine learning systems to assist in
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processing claims; prohibiting the use of artificial
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intelligence or machine learning systems as the sole
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basis for determining whether to reduce a claim
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payment or deny a claim or portion of a claim;
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requiring that insurers' decisions to deny a claim or
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portion of a claim or reduce a claim be made by
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qualified human professionals; specifying the duties
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of qualified human professionals; requiring an insurer
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to maintain certain records; requiring insurers to
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include certain information in denial communications
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to claimants; requiring that certain insurers detail
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certain information in their claims-handling manual;
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authorizing the Office of Insurance Regulation to
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conduct market conduct examinations and investigations
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under certain circumstances; authorizing the Financial
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Services Commission to adopt rules; creating s.
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641.31091, F.S.; defining terms; authorizing health
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maintenance organizations to use artificial
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intelligence systems and machine learning systems to
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assist in processing claims; prohibiting the use of
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artificial intelligence or machine learning systems as
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the sole basis for determining whether to reduce a
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claim payment or deny a claim or portion of a claim;
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requiring that health maintenance organizations'
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decisions to deny a claim or reduce a claim or portion
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of a claim be made by qualified human professionals;
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specifying the duties of qualified human
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professionals; requiring a health maintenance
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organization to maintain certain records; requiring
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health maintenance organizations to include certain
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information in denial communications to claimants;
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requiring that certain health maintenance
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organizations detail certain information in their
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claims-handling manual; authorizing the office to
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conduct market conduct examinations and investigations
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under certain circumstances; authorizing the
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commission to adopt rules; providing an effective
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date.
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Be It Enacted by the Legislature of the State of Florida:
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Section 1. Section 440.131, Florida Statutes, is created
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to read:
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440.131 Mandatory human reviews of claim denials.—
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(1) As used in this section, the term:
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(a) "Artificial intelligence system" means a machine-based
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system that may have varying levels of autonomy and that can,
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for a given set of objectives, generate outputs, such as
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predictions, recommendations, or content, influencing decisions
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made in real or virtual environments.
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(b) "Machine learning system" means an artificial
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intelligence system that has the ability to learn from provided
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data without being explicitly programmed.
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(c) "Qualified human professional" means an individual
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who, under the Florida Insurance Code, has the authority to
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adjust or deny a claim or a portion of a claim and may exercise
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such authority over a particular claim.
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(2) A carrier may use an artificial intelligence system or
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a machine learning system to assist in processing claims,
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including generating recommendations to reduce a claim payment
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or to approve or deny a claim or a portion of a claim, in
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accordance with this section.
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(3) A decision to reduce a claim payment or deny a claim
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or a portion of a claim may not be made solely on the basis of
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an artificial intelligence system or a machine learning system.
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A carrier's decision to reduce a claim payment or deny a claim
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or a portion of a claim must be made by a qualified human
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professional.
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(4) If an artificial intelligence system or a machine
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learning system assists in processing a claim, the qualified
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human professional must do all of the following before reducing
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a claim payment or denying the claim or a portion of the claim:
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(a) Analyze the facts of the claim and the terms of the
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insurance policy independently of any artificial intelligence
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system or machine learning system.
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(b) Review the accuracy of any output generated by such a
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system.
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(c) Determine that the claim or portion of the claim is
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not payable under the terms of the insurance policy and should
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be denied or that the claim payment should be reduced.
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(5) A carrier shall maintain detailed records of the
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actions of qualified human professionals who are required to
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perform the actions under subsection (4), including:
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(a) The name, the title, the business address, and the
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unique identifier associated with the name of the qualified
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human professional who made the decision to reduce the claim
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payment or deny the claim or a portion of the claim.
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(b) The date and time of the qualified human
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professional's decision.
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(c) Documentation of the basis for the reduction of the
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claim payment or denial of the claim or a portion of the claim,
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including any information provided by an artificial intelligence
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system or a machine learning system.
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(6) In all written denial communications to an injured
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employee, a carrier shall include:
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(a) An e-mail address, a telephone number, a business
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address, and a unique identifier, in lieu of the name of the
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qualified human professional who made the decision to reduce the
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claim payment or deny the claim or a portion of the claim; and
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(b) A written statement affirming that an artificial
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intelligence system or a machine learning system did not serve
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as the sole basis for determining whether to reduce the claim
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payment or deny the claim or a portion of the claim.
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(7) A carrier that uses an artificial intelligence system
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or a machine learning system as part of its claims-handling
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process shall detail in its claims-handling manual the manner in
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which such systems are to be used and the manner in which the
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carrier complies with this section.
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(8) The department may conduct examinations and
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investigations it deems necessary to verify compliance with this
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section.
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(9) The department may adopt rules to implement this
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section.
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(10) Failure to comply with this section shall be
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considered a violation of this chapter and is subject to
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penalties as provided for in s. 440.525.
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Section 2. Section 627.4263, Florida Statutes, is created
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to read:
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627.4263 Mandatory human reviews of claim denials.—
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(1) As used in this section, the term:
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(a) "Artificial intelligence system" means a machine-based
146
system that may have varying levels of autonomy and that can,
147
for a given set of objectives, generate outputs, such as
148
predictions, recommendations, or content, influencing decisions
149
made in real or virtual environments.
150
(b) "Machine learning system" means an artificial
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intelligence system that has the ability to learn from provided
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data without being explicitly programmed.
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(c) "Qualified human professional" means an individual
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who, under the Florida Insurance Code, has the authority to
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adjust or deny a claim or a portion of a claim and may exercise
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such authority over a particular claim.
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(2) An insurer may use an artificial intelligence system
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or machine learning system to assist in processing claims,
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including generating recommendations to reduce a payment or to
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approve or deny a claim or a portion of a claim, in accordance
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with this section.
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(3) A decision to reduce a claim payment or deny a claim
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or a portion of a claim may not be made solely on the basis of
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an artificial intelligence system or a machine learning system.
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An insurer's decision to reduce a claim payment or deny a claim
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or a portion of a claim must be made by a qualified human
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professional.
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(4) If an artificial intelligence system or a machine
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learning system assists in processing a claim, the qualified
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human professional must do all of the following before reducing
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a claim payment or denying the claim or a portion of the claim:
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(a) Analyze the facts of the claim and the terms of the
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insurance policy independently of any artificial intelligence
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system or machine learning system.
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(b) Review the accuracy of any output generated by such a
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system.
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(c) Determine that the claim or portion of the claim is
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not payable under the terms of the insurance policy and should
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be denied or that the claim payment should be reduced.
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(5) An insurer shall maintain detailed records of the
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actions of qualified human professionals who are required to
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perform the actions under subsection (4), including:
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(a) The name, the title, the business address, and the
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unique identifier associated with the name of the qualified
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human professional who made the decision to reduce the claim
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payment or deny the claim or a portion of the claim.
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(b) The date and time of the qualified human
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professional's decision.
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(c) Documentation of the basis for the reduction of the
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claim payment or denial of the claim or a portion of the claim,
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including any information provided by an artificial intelligence
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system or a machine learning system.
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(6) In all written denial communications to an insured, an
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insurer shall include:
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(a) An e-mail address, a telephone number, a business
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address, and a unique identifier, in lieu of the name of the
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qualified human professional who made the decision to reduce the
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claim payment or deny the claim or a portion of the claim; and
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(b) A written statement affirming that an artificial
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intelligence system or a machine learning system did not serve
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as the sole basis for determining whether to reduce the claim
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payment or deny the claim or a portion of the claim.
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(7) An insurer that uses an artificial intelligence system
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or a machine learning system as part of its claims-handling
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process shall detail in its claims-handling manual the manner in
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which such systems are to be used and the manner in which the
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insurer complies with this section.
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(8) The office may conduct market conduct examinations and
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investigations it deems necessary to verify compliance with this
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section.
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(9) The commission may adopt rules to implement this
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section.
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Section 3. Section 641.31091, Florida Statutes, is created
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to read:
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641.31091 Mandatory human reviews of claim denials.—
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(1) As used in this section, the term:
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(a) "Artificial intelligence system" means a machine-based
218
system that may have varying levels of autonomy and that can,
219
for a given set of objectives, generate outputs, such as
220
predictions, recommendations, or content, influencing decisions
221
made in real or virtual environments.
222
(b) "Machine learning system" means an artificial
223
intelligence system that has the ability to learn from provided
224
data without being explicitly programmed.
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(c) "Qualified human professional" means an individual
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who, under the Florida Insurance Code, has the authority to
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adjust or deny a claim or a portion of a claim and may exercise
228
such authority over a particular claim.
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(2) A health maintenance organization may use an
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artificial intelligence system or a machine learning system to
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assist in processing claims, including generating
232
recommendations to reduce a claim payment or to approve or deny
233
a claim or a portion of a claim, in accordance with this
234
section.
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(3) A decision to reduce a claim payment or deny a claim
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or a portion of a claim may not be made solely on the basis of
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an artificial intelligence system or machine learning system. A
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health maintenance organization's decision to reduce a claim
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payment or deny a claim or a portion of a claim must be made by
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a qualified human professional.
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(4) If an artificial intelligence system or a machine
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learning system assists in processing a claim, the qualified
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human professional must do all of the following before reducing
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a claim payment or denying the claim or a portion of the claim:
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(a) Analyze the facts of the claim and the terms of the
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health maintenance contract independently of any artificial
247
intelligence system or machine learning system.
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(b) Review the accuracy of any output generated by such a
249
system.
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(c) Determine that the claim or portion of the claim is
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not payable under the terms of the health maintenance contract
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and should be denied or that the claim payment should be
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reduced.
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(5) A health maintenance organization shall maintain
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detailed records of the actions of qualified human professionals
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who are required to perform the actions under subsection (4),
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including:
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(a) The name, the title, the business address, and the
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unique identifier associated with the name of the qualified
260
human professional who made the decision to reduce the claim
261
payment or deny the claim or a portion of the claim.
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(b) The date and time of the qualified human
263
professional's decision.
264
(c) Documentation of the basis for the reduction of the
265
claim payment or denial of the claim or a portion of the claim,
266
including any information provided by an artificial intelligence
267
system or a machine learning system.
268
(6) In all written denial communications to a subscriber,
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a health maintenance organization shall include:
270
(a) An e-mail address, a telephone number, a business
271
address, and a unique identifier, in lieu of the name of the
272
qualified human professional who made the decision to reduce the
273
claim payment or deny the claim or a portion of the claim; and
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(b) A written statement affirming that an artificial
275
intelligence system or a machine learning system did not serve
276
as the sole basis for determining whether to reduce the claim
277
payment or deny the claim or a portion of the claim.
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(7) A health maintenance organization that uses an
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artificial intelligence system or a machine learning system as
280
part of its claims-handling process shall detail in its claims-
281
handling manual the manner in which such systems are to be used
282
and the manner in which the health maintenance organization
283
complies with this section.
284
(8) The office may conduct market conduct examinations and
285
investigations or use any method it deems necessary to verify
286
compliance with this section.
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(9) The commission may adopt rules to implement this
288
section.
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Section 4. This act shall take effect July 1, 2026.