Hospital and Medical Services Utilization Review Act; requiring utilization review organization that uses AI to adhere to requirements; prohibiting AI from making certain determinations. Effective date.
SB1967 amends Oklahoma’s Hospital and Medical Services Utilization Review Act to regulate the use of artificial intelligence in health insurance utilization review. The bill defines “artificial intelligence” and “artificial intelligence tool” for purposes of utilization review and applies its requirements to utilization review organizations, disability insurers, and specialized health insurers that use AI directly or through a contractor. It requires AI-assisted review tools to rely on an enrollee’s medical and clinical history, the requesting provider’s clinical information, and other relevant records, rather than solely on group datasets, and it bars those tools from supplanting provider decision-making or discriminating against enrollees.
The bill also prohibits AI tools from denying, delaying, or modifying health care services based in whole or in part on medical necessity. Instead, medical necessity determinations must be made by a licensed physician or other qualified licensed health care professional who reviews the provider’s recommendation and the patient’s clinical circumstances. Health benefit plans must disclose on their websites whether they use AI in utilization review, and clinical peer reviewers must document review of individual clinical records before issuing an adverse determination when AI is used initially. The Insurance Commissioner is authorized to inspect AI tools, require disclosures in written policies and procedures, promulgate rules, and enforce penalties for violations.
SB1967 would add a new section to Title 36 and expand the state’s insurance utilization review framework to specifically govern AI-driven utilization management. It would impose compliance obligations on health benefit plans, utilization review organizations, disability insurers, and specialized health insurers, while giving the Insurance Commissioner oversight authority and rulemaking power. The bill also creates enforcement consequences, including fines, license suspension or revocation, and limits on new license issuance, with penalties applying in addition to other state or federal remedies.
The available record shows no committee transcript, vote tally, or recorded debate, so there is no direct evidence of support or opposition from floor or committee discussion. Based on the bill’s structure, it appears aimed at consumer protection and preserving clinician judgment in coverage decisions, suggesting a regulatory approach likely intended to address concerns about automated denials and opaque AI use in health insurance. The absence of recorded votes or testimony means the overall sentiment cannot be measured from the provided materials.
The main policy tension in SB1967 is between using AI to streamline utilization review and preventing automated systems from making or driving adverse coverage decisions. Supporters would likely emphasize patient protection, transparency, and the need for licensed professionals to make medical necessity determinations. Potential opponents or critics may focus on compliance burdens, operational costs, and the bill’s restrictions on insurer use of predictive tools and algorithmic decision support. Another point of contention is the breadth of the oversight and penalty regime, including Commissioner inspection authority and substantial aggregate fines.