▸SECTION 12
of Chapter 176O of the General Laws is hereby amended by inserting at the end thereof the following subsection:-
(g)(1) A carrier or a utilization review organization that uses an artificial intelligence, algorithm, or other software tool for the purpose of utilization review or utilization management functions, based in whole or in part on medical necessity, or that contracts with or otherwise works through an entity that uses an artificial intelligence, algorithm, or other software tool for the purpose of utilization review or utilization management functions, based in whole or in part on medical necessity, shall comply with this subsection and shall ensure all of the following:
(A) The artificial intelligence, algorithm, or other software tool bases its determination on the following information, as applicable:
(i) An insured’s medical or other clinical history.
(ii) Individual clinical circumstances as presented by the requesting provider.
(iii) Other relevant clinical information contained in the insured’s medical or other clinical record.
(B) The artificial intelligence, algorithm, or other software tool does not base its determination solely on a group dataset.
(C) The artificial intelligence, algorithm, or other software tools criteria and guidelines complies with this chapter and applicable state and federal law.
(D) The artificial intelligence, algorithm, or other software tool does not supplant health care provider decision-making.
(E) The use of the artificial intelligence, algorithm, or other software tool does not discriminate, directly or indirectly, against any insured in violation of state or federal law, including but not limited to chapter 151B.
(F) The artificial intelligence, algorithm, or other software tool is fairly and equitably applied, including in accordance with any applicable regulations and guidance issued by state and federal agencies.
(G) The artificial intelligence, algorithm, or other software tool is open to inspection for audit or compliance reviews by the division and by the executive office of health and human services pursuant to applicable state and federal law.
(H) Disclosures pertaining to the use and oversight of the artificial intelligence, algorithm, or other software tool are contained in the written policies and procedures, as required by subsection (a).
(I) The artificial intelligence, algorithm, or other software tools performance, use, and outcomes are periodically reviewed and revised to maximize accuracy and reliability.
(J) Patient data is not used beyond its intended and stated purpose, and consistent with state and federal law.
(K) The artificial intelligence, algorithm, or other software tool does not directly or indirectly cause harm to the insured.
(2) Notwithstanding paragraph (1), the artificial intelligence, algorithm, or other software 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, as provided in subsection (a), by reviewing and considering the requesting providers recommendation, the insured’s medical or other clinical history, as applicable, and individual clinical circumstances.
(3) For purposes of this subsection, artificial intelligence means an engineered or machine-based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.
(4) This subsection shall apply to utilization review or utilization management functions that prospectively, retrospectively, or concurrently review requests for covered health care services.
(5) A health benefit plan subject to this subsection shall comply with applicable state and federal rules and guidance regarding the use of artificial intelligence, algorithm, or other software tools. The division and the executive office of health and human services may issue guidance to implement this paragraph within one year of the adoption of state or federal rules or the issuance of guidance by the federal Department of Health and Human Services regarding the use of artificial intelligence, algorithm, or other software tools. Such guidance shall not be subject to chapter 30A.
(6) This subsection applies to a MassHealth managed health benefit plan only to the extent that the executive office of health and human services obtains any necessary federal approvals, and federal financial participation is not otherwise jeopardized.
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Section 12 of Chapter 176O of the General Laws is hereby amended by inserting at the end thereof the following subsection:-
(g)(1) A carrier or a utilization review organization that uses an artificial intelligence, algorithm, or other software tool for the purpose of utilization review or utilization management functions, based in whole or in part on medical necessity, or that contracts with or otherwise works through an entity that uses an artificial intelligence, algorithm, or other software tool for the purpose of utilization review or utilization management functions, based in whole or in part on medical necessity, shall comply with this subsection and shall ensure all of the following:
(A) The artificial intelligence, algorithm, or other software tool bases its determination on the following information, as applicable:
(i) An insured’s medical or other clinical history.
(ii) Individual clinical circumstances as presented by the requesting provider.
(iii) Other relevant clinical information contained in the insured’s medical or other clinical record.
(B) The artificial intelligence, algorithm, or other software tool does not base its determination solely on a group dataset.
(C) The artificial intelligence, algorithm, or other software tools criteria and guidelines complies with this chapter and applicable state and federal law.
(D) The artificial intelligence, algorithm, or other software tool does not supplant health care provider decision-making.
(E) The use of the artificial intelligence, algorithm, or other software tool does not discriminate, directly or indirectly, against any insured in violation of state or federal law, including but not limited to chapter 151B.
(F) The artificial intelligence, algorithm, or other software tool is fairly and equitably applied, including in accordance with any applicable regulations and guidance issued by state and federal agencies.
(G) The artificial intelligence, algorithm, or other software tool is open to inspection for audit or compliance reviews by the division and by the executive office of health and human services pursuant to applicable state and federal law.
(H) Disclosures pertaining to the use and oversight of the artificial intelligence, algorithm, or other software tool are contained in the written policies and procedures, as required by subsection (a).
(I) The artificial intelligence, algorithm, or other software tools performance, use, and outcomes are periodically reviewed and revised to maximize accuracy and reliability.
(J) Patient data is not used beyond its intended and stated purpose, and consistent with state and federal law.
(K) The artificial intelligence, algorithm, or other software tool does not directly or indirectly cause harm to the insured.
(2) Notwithstanding paragraph (1), the artificial intelligence, algorithm, or other software 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, as provided in subsection (a), by reviewing and considering the requesting providers recommendation, the insured’s medical or other clinical history, as applicable, and individual clinical circumstances.
(3) For purposes of this subsection, artificial intelligence means an engineered or machine-based system that varies in its level of autonomy and that can, for explicit or implicit objectives, infer from the input it receives how to generate outputs that can influence physical or virtual environments.
(4) This subsection shall apply to utilization review or utilization management functions that prospectively, retrospectively, or concurrently review requests for covered health care services.
(5) A health benefit plan subject to this subsection shall comply with applicable state and federal rules and guidance regarding the use of artificial intelligence, algorithm, or other software tools. The division and the executive office of health and human services may issue guidance to implement this paragraph within one year of the adoption of state or federal rules or the issuance of guidance by the federal Department of Health and Human Services regarding the use of artificial intelligence, algorithm, or other software tools. Such guidance shall not be subject to chapter 30A.
(6) This subsection applies to a MassHealth managed health benefit plan only to the extent that the executive office of health and human services obtains any necessary federal approvals, and federal financial participation is not otherwise jeopardized.