CA SB1120

Requires health care service plans and disability insurers using artificial intelligence, algorithms, or software tools for utilization review or utilization management to base determinations on individual enrollee/insured medical history, clinical circumstances, and medical records rather than solely on group datasets.

Prohibits AI, algorithm, or software tools from denying, delaying, or modifying health care services based on medical necessity; medical necessity determinations must be made by licensed physicians or qualified health care professionals who review provider recommendations and individual clinical circumstances.

Mandates that AI, algorithm, or software tools must not discriminate against enrollees/insureds, must be fairly and equitably applied, must not supplant provider decisionmaking, and must be open to inspection for audit or compliance reviews by regulatory departments.

Requires health care plans and insurers to include disclosures about AI, algorithm, or software tool use and oversight in written policies and procedures, and to periodically review and revise performance to maximize accuracy and reliability.

Applies requirements to health care service plans, specialized health care service plans, disability insurers, and specialized health insurers that use these tools or contract with entities that use them for utilization review or utilization management functions.