Pennsylvania's House wants a clinician behind every AI denial

If HB 1925 becomes law, a health insurer in Pennsylvania that uses AI in utilization review would have to say so, and every denial would need a health care provider’s documented review of the clinical records. The House passed it 144 to 59 on September 30. On October 14 it was referred to the Senate’s Institutional Sustainability and Innovation Committee, and the bill’s page showed no later action when we read it on October 27.

This week’s story: what HB 1925 would ask of insurers

HB 1925 would add three chapters, for health care facilities, Medicaid and CHIP managed care plans, and insurers. We follow the third. An insurer that uses or will use AI in utilization review would disclose that use to participating network providers and all covered persons, in plain language and on its website.

AI used on any covered person’s case would have to meet conditions, including evaluating that person’s clinical history and circumstances and not producing an output “solely based on a group data set.” The insurer would attest to full compliance, governance included, in an annual statement to the Insurance Department.

The health care provider reviewing the case would examine the individual clinical records and document the review before a decision to deny, reduce or terminate benefits is issued or upheld, including a prior authorization denial. The bill defines that provider as a facility or individual licensed or otherwise regulated to provide health care in Pennsylvania. The provider would then exercise judgment “independent of any recommendations by artificial intelligence models or systems.” The insurer could not penalize the provider solely for overturning such an AI-generated decision or for refusing to issue one.

The department could impose fines of not more than $10,000 per knowing or willful violation and temporarily bar a violator from enrolling new covered persons.

The state constitution makes the General Assembly a continuing body during its representatives’ term, which ends November 30. On our reading, a bill not enacted by then would have to be introduced again.

What to do this week

HB 1925 would take effect a year after enactment and require nothing until then, so these are our suggestions for getting ready.

• Start with the case file. Pull a recent Pennsylvania denial in which AI played a part, and see whether the file shows a health care provider examining the individual clinical records and documenting that review. Add one where a denial was upheld, because the duty would cover that too.

• Sort the AI in your utilization review by whether it bears on an adverse benefit decision. The bill would exempt the rest, such as scheduling and other administrative uses. Pennsylvania adopted the NAIC model bulletin in April 2024, and the AI program you keep under it can hold that sort now, whether or not the bill passes.

• If you use a vendor’s AI in utilization review, read the contract against the bill’s vendor section. The section would require you to set up your own internal review and governance processes covering the duties described above. It would also let you make compliance with the chapter a term of the vendor contract, so check whether yours already has one.

• Given the bill’s protection for reviewers who overturn the AI, look at how reviewers are scored. A productivity or quality measure that counts disagreement with the model against the reviewer is the first thing to check.

On the Docket

• October 30, 2026: Written comments on version 6.0 of the AI Risk Evaluation Supplement are due by close of business. The NAIC exposed it through its Big Data and Artificial Intelligence (H) Working Group. NAIC working group page

• November 2, 2026: The working group holds a public Webex at 10:00 AM CT. Its page lists no meeting materials yet. NAIC working group page

• November 5, 2026: Plaintiffs in Barrows v. Humana, a class action in the Western District of Kentucky, must file their class certification motion. They allege that Humana used the nH Predict model to make coverage determinations. On October 15 the court declined to pause the class certification deadlines pending its ruling on the plaintiffs’ September 29 request to add naviHealth as a defendant. Humana opposed that request on October 20. October 15 scheduling order

• November 14, 2026: The NAIC Fall National Meeting opens in Dallas and runs through November 17. The working group meets there on November 16. Fall National Meeting schedule

• November 19, 2026: The National Council of Insurance Legislators (NCOIL) holds its annual meeting in Sanibel, Florida, through November 22. Its schedule lists a dialogue with the NAIC that includes an update on the working group’s work. NCOIL marks the schedule subject to change. NCOIL meeting materials

This week in brief

Business Lines

Records released to EFF in its FOIA suit against CMS and reported by the Columbus Dispatch on October 22 include a December 12, 2025, letter in which Innovaccer, Ohio’s contractor in the WISeR pilot for Original Medicare, said it would at first “auto-affirm all prior authorization requests” while it built out functionality. A weekly report from CGS, the Medicare contractor for Ohio’s region, forwarded on March 30, 2026, counted 584 requests on hold awaiting Innovaccer’s determination and 517 decision letters outstanding.

From the Guides

For health plans. Our guide takes prior authorization, claims adjudication and risk adjustment one at a time: Prior Authorization Is Where Health AI Gets Tested.

If you track other state bills on AI in utilization review, reply with the one you would want us to read next.

– The Editor, InsureAI Wire