IA SSB3118

Prohibits utilization review organizations from using artificial intelligence as the sole basis to deny, delay, or downgrade prior authorization requests for health care services based on medical necessity

Requires denials or downgrades of prior authorization requests to be made by a qualified reviewer (physician in same/similar specialty) when the requesting provider is a physician, or by a clinical peer when the requesting provider is not a physician

Establishes peer review requirements mandating that reviewers have training and expertise in the specific medical condition and be employed by or contracted with the utilization review organization or health carrier

Mandates that utilization review organizations provide written statements citing specific reasons for denials or downgrades, including coverage criteria, clinical criteria, and limits used in the decision

Defines "downgrade" as changing an expedited or urgent prior authorization request to a standard determination, or modifying a requested health care service to a lower-level service