No. CS/CS/HB 527
Filed under Insurance.
Mandatory Human Reviews of Insurance Claim Denials ; Authorizes workers' compensation carriers, insurers &HMOs to use artificial intelligence systems & machine learning systems to assist in processing claims; prohibits use of artificial intelligence or machine learning systems as sole basis for determining whether to reduce claim payment or deny claim or portion of claim; requires that decisions to deny claim or portion of claim or reduce claim be made by qualified human professionals; authorizes OIR to conduct market conduct examinations & investigations.
Plain English Summary
AI-GENERATEDThis bill lets workers' compensation carriers, insurers, and HMOs use artificial intelligence or machine learning to help process claims, but the final call to deny a claim or reduce a payment must be made by a qualified human professional.
Before denying a claim or cutting its payment, the human professional must independently analyze the facts and policy terms, check any AI output's accuracy, and determine the claim is not payable or should be reduced.
Denial letters must give the claimant an e-mail address, phone number, and unique identifier for the deciding professional, but need not include that person's actual name.
Each of the three carrier types must keep detailed records of every human reviewer's decision, and workers' compensation carriers specifically face existing penalties under s. 440.525 for failing to comply.
AIA workers' compensation carrier, insurer, or HMO may use an artificial intelligence system or machine learning system to help process claims, including generating recommendations to deny a claim or reduce its payment.
AIA decision to deny a claim, deny part of one, or reduce its payment can never rest solely on what an AI or machine learning system produced; a human decision is always required in addition.
AIBefore denying or reducing a claim, the human professional must independently analyze the facts and policy terms and personally determine that the claim is not payable and should be denied.
AIA written denial must include an e-mail address, phone number, business address, and unique identifier for the deciding professional, used in place of that person's actual name.
AIOnly in the workers' compensation section, failing to comply with these requirements is treated as a violation subject to the penalties already set out in s. 440.525.
AICarriers must keep records including the name, title, business address, and a unique identifier for the qualified human professional who made each denial or reduction decision.
AIEvery written denial must include a statement affirming that an AI or machine learning system did not serve as the sole basis for the decision to deny or reduce the claim.
AIA carrier that uses AI or machine learning anywhere in claims handling must explain in its claims-handling manual how those systems are used and how it complies with this section.