Health care coverage: prior authorization.

Assembly Member Harabedian's health care coverage legislation aims to accelerate prior authorization decisions and establish guardrails for artificial intelligence use in utilization review processes. The bill reduces standard authorization timeframes from five business days to three days for electronic submissions while maintaining the five-day window for non-electronic requests. For urgent cases involving serious health threats, decisions must be made within 24 hours for electronic submissions and 48 hours for non-electronic requests.

The measure creates a comprehensive framework for health plans and insurers using AI tools in utilization management. These systems must base determinations on individual clinical data rather than solely group datasets, cannot replace provider decision-making, and must undergo regular performance reviews. The legislation requires AI tools to be open to regulatory inspection and mandates that their use comply with anti-discrimination laws and data privacy requirements.

Health plans and insurers must integrate these changes into their quality assurance programs and face administrative penalties for non-compliance. The bill maintains existing requirements for licensed medical professionals to make final determinations on medical necessity and preserves enrollees' rights to appeal denied services. While the legislation imposes new operational requirements on plans and insurers, it explicitly states that these entities are not to be classified as health care providers under various state laws.