Senate Bill S10241

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   10241
 
                             I N  S E N A T E
 
                                May 8, 2026
                                ___________
 
 Introduced  by  Sen. HINCHEY -- read twice and ordered printed, and when
   printed to be committed to the Committee on Insurance
 
 AN ACT to amend the insurance law and the public health law, in relation
   to the use of artificial intelligence for utilization review
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:

   Section 1. The insurance law is amended by adding a new section 338 to
 read as follows:
   §  338.  NOTIFICATION REGARDING THE USE OF ARTIFICIAL INTELLIGENCE FOR
 UTILIZATION REVIEW. (A) AS USED IN THIS  SECTION,  THE  FOLLOWING  TERMS
 SHALL HAVE THE FOLLOWING MEANINGS:
   (1)  "ADVERSE  DETERMINATION" SHALL HAVE THE SAME MEANING AS SUCH TERM
 IS DEFINED BY SECTION FORTY-NINE HUNDRED OF THIS CHAPTER.
   (2) "ARTIFICIAL INTELLIGENCE-BASED  ALGORITHM"  MEANS  ANY  ALGORITHM-
 BASED SYSTEM THAT CAN, FOR A GIVEN SET OF HUMAN-DEFINED OBJECTIVES, MAKE
 PREDICTIONS, RECOMMENDATIONS AND/OR DECISIONS INFLUENCING REAL OR VIRTU-
 AL ENVIRONMENTS. AN ARTIFICIAL INTELLIGENCE-BASED ALGORITHM USES MACHINE
 AND HUMAN-BASED INPUTS TO:
   (A) PERCEIVE REAL AND VIRTUAL ENVIRONMENTS;
   (B) ABSTRACT SUCH PERCEPTIONS INTO MODELS THROUGH ANALYSIS IN AN AUTO-
 MATED MANNER; AND
   (C)  USE  MODEL  INFERENCE  TO  FORMULATE  OPTIONS  FOR INFORMATION OR
 ACTION.
   (3) "CLINICAL PEER REVIEWER" SHALL HAVE THE SAME MEANING AS SUCH  TERM
 IS DEFINED BY SECTION FORTY-NINE HUNDRED OF THIS CHAPTER.
   (4)  "EMERGENCY CONDITION" SHALL HAVE THE SAME MEANING AS SUCH TERM IS
 DEFINED BY SECTION FORTY-NINE HUNDRED OF THIS CHAPTER.
   (5) "HEALTH CARE PROVIDER" SHALL HAVE THE SAME MEANING AS SUCH TERM IS
 DEFINED BY SECTION THIRTY-TWO HUNDRED TWENTY-FOUR-A OF THIS CHAPTER.
   (6) "INSURER" MEANS AN INSURER AUTHORIZED TO WRITE ACCIDENT AND HEALTH
 INSURANCE IN THIS STATE, A CORPORATION  ORGANIZED  PURSUANT  TO  ARTICLE
 FORTY-THREE  OF  THIS  CHAPTER,  AND  A  HEALTH MAINTENANCE ORGANIZATION
 CERTIFIED PURSUANT TO ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW.
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD15313-01-6
              

 S. 10241                            2
 
   (7) "UTILIZATION REVIEW" SHALL HAVE THE SAME MEANING AS SUCH  TERM  IS
 DEFINED BY SECTION FORTY-NINE HUNDRED OF THIS CHAPTER.
   (B)(1)  THE SUPERINTENDENT SHALL REQUIRE ALL INSURERS TO PROVIDE WRIT-
 TEN NOTICE TO INSUREDS, ENROLLEES, AND HEALTH CARE PROVIDERS  ABOUT  THE
 USE  OF  ARTIFICIAL  INTELLIGENCE-BASED  ALGORITHMS IN THEIR UTILIZATION
 REVIEW PROCESS. SUCH WRITTEN NOTICE SHALL BE SENT  WHEN  THE  ARTIFICIAL
 INTELLIGENCE-BASED  ALGORITHM  IS  FIRST ADOPTED BY THE INSURER AND ONCE
 DURING EACH SUBSEQUENT POLICY PERIOD. IN ADDITION, SUCH  INSURERS  SHALL
 PROVIDE A CLEAR AND CONSPICUOUS NOTICE ON THEIR WEBSITES ABOUT THEIR USE
 OF  ARTIFICIAL  INTELLIGENCE-BASED  ALGORITHMS IN THE UTILIZATION REVIEW
 PROCESS.
   (2) IF ARTIFICIAL INTELLIGENCE-BASED ALGORITHMS ARE USED IN THE UTILI-
 ZATION REVIEW PROCESS, EACH INSURER SHALL DISCLOSE TO THE  INSURED'S  OR
 ENROLLEE'S  HEALTH  CARE  PROVIDER, AND, UPON REQUEST, TO THE INSURED OR
 ENROLLEE, THE FOLLOWING INFORMATION: THE CRITERIA GOVERNING SUCH ARTIFI-
 CIAL INTELLIGENCE-BASED ALGORITHM, THE DATA  SETS  USED  TO  TRAIN  SUCH
 ARTIFICIAL  INTELLIGENCE-BASED  ALGORITHM,  THE ARTIFICIAL INTELLIGENCE-
 BASED ALGORITHM ITSELF, AND THE OUTCOMES PRODUCED BY SOFTWARE THAT  USES
 THE ARTIFICIAL INTELLIGENCE-BASED ALGORITHM.
   (3)  AN  INSURER'S  USE OF ARTIFICIAL INTELLIGENCE-BASED ALGORITHMS IN
 THE UTILIZATION REVIEW PROCESS SHALL BE  DISCLOSED  TO  THE  INSURED  OR
 ENROLLEE  AND TO THE INSURED'S OR ENROLLEE'S HEALTH CARE PROVIDER IN THE
 NOTICE OF AN ADVERSE  DETERMINATION  MADE  BY  CLINICAL  PEER  REVIEWERS
 PURSUANT  TO  SUBSECTION (E) OF SECTION FORTY-NINE HUNDRED THREE OF THIS
 CHAPTER AND SUBDIVISION FIVE OF SECTION FORTY-NINE HUNDRED THREE OF  THE
 PUBLIC HEALTH LAW.
   (4)  ANY ARTIFICIAL INTELLIGENCE-BASED ALGORITHMS USED IN THE UTILIZA-
 TION REVIEW PROCESS BY AN INSURER SHALL NOT  BASE  AN  ADVERSE  DETERMI-
 NATION SOLELY ON A GROUP DATA SET.
   (5)  ANY ARTIFICIAL INTELLIGENCE-BASED ALGORITHMS USED IN THE UTILIZA-
 TION REVIEW PROCESS BY AN INSURER SHALL NOT DIRECTLY OR INDIRECTLY CAUSE
 HARM TO THE INSURED OR ENROLLEE.
   (6) ANY ARTIFICIAL INTELLIGENCE-BASED ALGORITHMS USED IN THE  UTILIZA-
 TION  REVIEW PROCESS BY AN INSURER SHALL BE OPEN TO INSPECTION FOR AUDIT
 OR COMPLIANCE REVIEWS BY THE SUPERINTENDENT IN ACCORDANCE WITH  APPLICA-
 BLE STATE AND FEDERAL LAWS.
   (7)  INSURED  AND  ENROLLEE DATA SHALL NOT BE USED BEYOND ITS INTENDED
 AND STATED PURPOSE, CONSISTENT WITH THE FEDERAL HEALTH INSURANCE  PORTA-
 BILITY AND ACCOUNTABILITY ACT OF 1996, AS APPLICABLE.
   (C) EVERY INSURER SHALL SUBMIT THE ARTIFICIAL INTELLIGENCE-BASED ALGO-
 RITHMS AND TRAINING DATA SETS THAT ARE BEING USED OR WILL BE USED IN THE
 UTILIZATION  REVIEW  PROCESS  TO  THE SUPERINTENDENT.   SUCH SUBMISSIONS
 SHALL INCLUDE, AT A MINIMUM, A CERTIFICATION THAT SUCH ARTIFICIAL INTEL-
 LIGENCE-BASED ALGORITHMS AND TRAINING DATA SETS:
   (1) HAVE MINIMIZED THE RISK OF BIAS  BASED  ON  THE  COVERED  PERSON'S
 RACE,  COLOR,  RELIGIOUS  CREED,  ANCESTRY,  AGE,  SEX, GENDER, NATIONAL
 ORIGIN, HANDICAP OR DISABILITY, AND ARE CONSISTENT WITH STATE AND FEDER-
 AL ANTIDISCRIMINATION LAWS;
   (2) ADHERE TO EVIDENCE-BASED CLINICAL GUIDELINES;
   (3) DO NOT RELY ON INFORMATION THAT IS  NOT  IN  COMPLIANCE  WITH  THE
 REQUIREMENTS  FOR  UTILIZATION  REVIEW  PURSUANT  TO  SECTION FORTY-NINE
 HUNDRED THREE OF THIS CHAPTER AND SECTION FORTY-NINE  HUNDRED  THREE  OF
 THE PUBLIC HEALTH LAW; AND
   (4)  DO NOT INDEPENDENTLY CREATE OR CHANGE CLINICAL STANDARDS OR OTHER
 COVERAGE CRITERIA.
 S. 10241                            3
 
   (D)(1) AN INSURER WITH A UTILIZATION  REVIEW  PROCESS  THAT  INITIALLY
 USES ARTIFICIAL INTELLIGENCE-BASED ALGORITHMS, SHALL ENSURE THAT ADVERSE
 DETERMINATIONS ARE MADE ONLY BY CLINICAL PEER REVIEWERS. A CLINICAL PEER
 REVIEWER WHO PARTICIPATES IN A UTILIZATION REVIEW PROCESS FOR AN INSURER
 THAT  INITIALLY  USES  ARTIFICIAL  INTELLIGENCE-BASED  ALGORITHMS  FOR A
 UTILIZATION REVIEW SHALL, PRIOR TO  ISSUING  AN  ADVERSE  DETERMINATION:
 CONSIDER  THE REQUESTING HEALTH PROVIDER'S RECOMMENDATION, THE INSURED'S
 OR ENROLLEE'S MEDICAL OR OTHER  CLINICAL  HISTORY,  AS  APPLICABLE,  AND
 INDIVIDUAL  CLINICAL  CIRCUMSTANCES;  OPEN  AND DOCUMENT THE UTILIZATION
 REVIEW OF THE INDIVIDUAL CLINICAL RECORDS AND DATA; AND COMPLY WITH  ALL
 REQUIREMENTS  OF  ARTICLE  FORTY-NINE OF THIS CHAPTER AND ARTICLE FORTY-
 NINE OF THE PUBLIC HEALTH LAW REGARDING UTILIZATION REVIEW. IN ADDITION,
 A UTILIZATION REVIEW DETERMINATION WITH RESPECT TO AN  EMERGENCY  CONDI-
 TION  SHALL  REQUIRE  APPLICATION OF A PRUDENT LAYPERSON STANDARD TO THE
 PATIENT'S PRESENTING SYMPTOMS, WITHOUT REGARD TO FINAL DIAGNOSIS.
   (2) EVERY INSURER SHALL SUBMIT TO THE SUPERINTENDENT, IN SUCH FORM AND
 MANNER AS THE SUPERINTENDENT MAY REQUIRE, DATA ON THE AMOUNT OF  TIME  A
 CLINICAL  PEER  REVIEWER SPENDS EXAMINING AN ADVERSE DETERMINATION PRIOR
 TO SIGNING OFF ON EACH ADVERSE DETERMINATION.
   (3) AN ARTIFICIAL INTELLIGENCE-BASED ALGORITHM SHALL NOT BE  THE  SOLE
 BASIS  OF  AN  INSURER'S  DECISION TO DENY, DELAY, OR MODIFY HEALTH CARE
 SERVICES BASED, IN WHOLE OR IN PART, ON MEDICAL NECESSITY.
   (4) EVERY CLINICAL PEER REVIEWER THAT PARTICIPATES  IN  A  UTILIZATION
 REVIEW PROCESS FOR AN INSURER ISSUING ADVERSE DETERMINATIONS SHALL ISSUE
 A SIGNED STATEMENT IN ACCORDANCE WITH PARAGRAPH ONE OF SUBSECTION (E) OF
 SECTION  FORTY-NINE  HUNDRED  THREE  OF THIS CHAPTER OR PARAGRAPH (A) OF
 SUBDIVISION FIVE OF SECTION  FORTY-NINE  HUNDRED  THREE  OF  THE  PUBLIC
 HEALTH LAW.
   (E) EVERY INSURER SHALL ESTABLISH AN ONGOING QUALITY ASSURANCE TESTING
 PROCESS  THAT MEETS ANY REQUIREMENTS THAT THE SUPERINTENDENT MAY SPECIFY
 WITH DEFINED PARAMETERS ON SAFETY AND EFFICACY OF ALL ARTIFICIAL  INTEL-
 LIGENCE-BASED  ALGORITHMS,  AND SHALL SUBMIT THE RESULTS OF SUCH QUALITY
 ASSURANCE TESTING PROCESS TO THE SUPERINTENDENT AT SUCH TIME AND IN SUCH
 FORM AND  MANNER  AS  THE  SUPERINTENDENT  MAY  SPECIFY,  BUT  NOT  LESS
 FREQUENTLY  THAN  SEMIANNUALLY.  THE  RESULTS  OF SUCH QUALITY ASSURANCE
 TESTING PROCESS SHALL BE PUBLISHED ON A  PUBLIC  WEBSITE  WITHIN  THIRTY
 DAYS OF THE SUBMISSION OF SUCH RESULTS TO THE SUPERINTENDENT.
   (F) (1) A VIOLATION OF THE PROVISIONS OF THIS SECTION SHALL BE SUBJECT
 TO  ONE  OR  MORE  OF  THE  FOLLOWING PENALTIES AT THE DISCRETION OF THE
 SUPERINTENDENT, IN CONSULTATION WITH THE COMMISSIONER OF HEALTH AND  THE
 COMMISSIONER OF EDUCATION AS APPLICABLE:
   (A) WHERE A VIOLATION IS MADE BY AN INSURER:
   (I) SUSPENSION OR REVOCATION OF LICENSE;
   (II)  REFUSAL,  FOR  A  PERIOD  NOT TO EXCEED ONE YEAR, TO ISSUE A NEW
 LICENSE;
   (III) A FINE OF NOT MORE THAN FIVE THOUSAND DOLLARS FOR EACH VIOLATION
 OF THIS SECTION; OR
   (IV) A FINE OF NOT MORE THAN TEN THOUSAND  DOLLARS  FOR  EACH  WILLFUL
 VIOLATION OF THIS SECTION.
   FINES  IMPOSED  PURSUANT  TO  THE PROVISIONS OF THIS SUBPARAGRAPH ON A
 SINGLE INSURER SHALL NOT EXCEED FIVE HUNDRED THOUSAND DOLLARS IN  AGGRE-
 GATE DURING A CALENDAR YEAR.
   (B) WHERE A VIOLATION IS MADE BY A CLINICAL PEER REVIEWER:
   (I) SUSPENSION OR REVOCATION OF LICENSE;
   (II)  REFUSAL,  FOR  A  PERIOD  NOT TO EXCEED ONE YEAR, TO ISSUE A NEW
 LICENSE;
 S. 10241                            4
 
   (III) A FINE OF NOT MORE THAN FIVE THOUSAND DOLLARS FOR EACH VIOLATION
 OF THIS SECTION; OR
   (IV)  A  FINE  OF  NOT MORE THAN TEN THOUSAND DOLLARS FOR EACH WILLFUL
 VIOLATION OF THIS SECTION.
   FINES IMPOSED PURSUANT TO THE PROVISIONS OF  THIS  SUBPARAGRAPH  ON  A
 SINGLE  CLINICAL  PEER  REVIEWER  SHALL  NOT EXCEED ONE HUNDRED THOUSAND
 DOLLARS IN AGGREGATE DURING A CALENDAR YEAR.
   (2) PENALTIES PURSUANT TO THE PROVISIONS OF THIS SUBSECTION  SHALL  BE
 IN ADDITION TO ANY OTHER REMEDIES OR PENALTIES THAT MAY BE IMPOSED UNDER
 ANY OTHER APPLICABLE LAW.
   (G)  THE  SUPERINTENDENT  SHALL  PROMULGATE  ALL RULES AND REGULATIONS
 NECESSARY FOR THE IMPLEMENTATION OF THIS SECTION.
   § 2. Subparagraph (C) of paragraph 9 of subsection (i) of section 3216
 of the insurance law, as amended by chapter 219 of the laws of 2011,  is
 amended to read as follows:
   (C)  For  purposes of this paragraph, an "emergency condition" means a
 medical or behavioral condition that, REGARDLESS OF THE FINAL DIAGNOSIS,
 manifests itself by acute symptoms  of  sufficient  severity,  including
 severe  pain, such that a prudent layperson, possessing an average know-
 ledge of medicine and health, could reasonably  expect  the  absence  of
 immediate  medical  attention to result in (i) placing the health of the
 person afflicted with such condition in serious jeopardy, or in the case
 of a behavioral condition placing the health of such person or others in
 serious jeopardy; (ii) serious impairment to such person's bodily  func-
 tions;  (iii)  serious  dysfunction  of any bodily organ or part of such
 person; (iv) serious disfigurement of such person; or  (v)  a  condition
 described  in  clause (i), (ii) or (iii) of section 1867(e)(1)(A) of the
 Social Security Act.
   § 3. Item (ii) of subparagraph (E) of paragraph 24 of  subsection  (i)
 of  section  3216 of the insurance law, as amended by chapter 219 of the
 laws of 2011, is amended to read as follows:
   (ii) "Emergency condition" means a  medical  or  behavioral  condition
 that,  REGARDLESS OF FINAL DIAGNOSIS, manifests itself by acute symptoms
 of sufficient severity, including  severe  pain,  such  that  a  prudent
 layperson, possessing an average knowledge of medicine and health, could
 reasonably  expect  the absence of immediate medical attention to result
 in (I) placing the health of the person afflicted with such condition in
 serious jeopardy, or in the case of a behavioral condition  placing  the
 health  of  such  person  or  others  in  serious jeopardy; (II) serious
 impairment to such person's bodily functions; (III) serious  dysfunction
 of  any  bodily organ or part of such person; (IV) serious disfigurement
 of such person; or (V) a condition described in  clause  (i),  (ii),  or
 (iii) of section 1867(e)(1)(A) of the Social Security Act.
   § 4. Subparagraph (C) of paragraph 4 of subsection (k) of section 3221
 of  the insurance law, as amended by chapter 219 of the laws of 2011, is
 amended to read as follows:
   (C) In this paragraph, an "emergency condition"  means  a  medical  or
 behavioral  condition that, REGARDLESS OF THE FINAL DIAGNOSIS, manifests
 itself by acute symptoms of sufficient severity, including severe  pain,
 such  that a prudent layperson, possessing an average knowledge of medi-
 cine and health,  could  reasonably  expect  the  absence  of  immediate
 medical  attention  to  result  in  (i) placing the health of the person
 afflicted with such condition in serious jeopardy, or in the case  of  a
 behavioral  condition  placing  the  health  of such person or others in
 serious jeopardy; (ii) serious impairment to such person's bodily  func-
 tions;  (iii)  serious  dysfunction  of any bodily organ or part of such
 S. 10241                            5
 
 person; (iv) serious disfigurement of such person; or  (v)  a  condition
 described  in  clause (i), (ii) or (iii) of section 1867(e)(1)(A) of the
 Social Security Act.
   § 5. Subparagraph (C) of paragraph 2 of subsection (a) of section 4303
 of  the insurance law, as amended by chapter 219 of the laws of 2011, is
 amended to read as follows:
   (C) For the purpose of this provision, "emergency condition"  means  a
 medical or behavioral condition that, REGARDLESS OF THE FINAL DIAGNOSIS,
 manifests  itself  by  acute  symptoms of sufficient severity, including
 severe pain, such that a prudent layperson, possessing an average  know-
 ledge  of  medicine  and  health, could reasonably expect the absence of
 immediate medical attention to result in (i) placing the health  of  the
 person afflicted with such condition in serious jeopardy, or in the case
 of a behavioral condition placing the health of such person or others in
 serious  jeopardy; (ii) serious impairment to such person's bodily func-
 tions; (iii) serious dysfunction of any bodily organ  or  part  of  such
 person;  (iv)  serious  disfigurement of such person; or (v) a condition
 described in clause (i), (ii) or (iii) of section 1867(e)(1)(A)  of  the
 Social Security Act.
   §  6.  Subsection (c) of section 4900 of the insurance law, as amended
 by chapter 219 of the laws of 2011, is amended to read as follows:
   (c) "Emergency condition" means a medical or  behavioral  condition[,]
 that, REGARDLESS OF THE FINAL DIAGNOSIS, manifests itself by acute symp-
 toms  of sufficient severity, including severe pain, such that a prudent
 layperson, possessing an average knowledge of medicine and health, could
 reasonably expect the absence of immediate medical attention  to  result
 in (1) placing the health of the person afflicted with such condition in
 serious  jeopardy,  or in the case of a behavioral condition placing the
 health of such person or others in serious jeopardy; (2) serious impair-
 ment to such person's bodily functions; (3) serious dysfunction  of  any
 bodily  organ  or part of such person; (4) serious disfigurement of such
 person; or (5) a condition described in clause (i),  (ii)  or  (iii)  of
 section 1867(e)(1)(A) of the Social Security Act.
   §  7.  Subdivision  3  of  section  4900  of the public health law, as
 amended by  chapter 219 of the laws of  2011,  is  amended  to  read  as
 follows:
   3.  "Emergency  condition"  means a medical or behavioral condition[,]
 that, REGARDLESS OF THE FINAL DIAGNOSIS, manifests itself by acute symp-
 toms of sufficient severity, including severe pain, such that a  prudent
 layperson, possessing an average knowledge of medicine and health, could
 reasonably  expect  the absence of immediate medical attention to result
 in (a) placing the health of the person afflicted with such condition in
 serious jeopardy, or in the case of a behavioral condition, placing  the
 health of such person or others in serious jeopardy; (b) serious impair-
 ment  to  such person's bodily functions; (c) serious dysfunction of any
 bodily organ or part of such person; (d) serious disfigurement  of  such
 person;  or  (e)  a  condition described in clause (i), (ii) or (iii) of
 section 1867(e)(1)(A) of the Social Security Act.
   § 8. Paragraph 1 of subsection (e) of section 4903  of  the  insurance
 law, as amended by chapter 28 of the laws of 2024, is amended to read as
 follows:
   (1)  Notice  of  an adverse determination made by a utilization review
 agent shall be in writing and must include:
   (i) the reasons for the determination including the  clinical  ration-
 ale,  if  any,  AND THE SPECIFIC COVERAGE OR CLINICAL CRITERIA THAT WERE
 NOT  SATISFIED,  INCLUDING  EXPLICIT  IDENTIFICATION  OF  THE   RELEVANT
 S. 10241                            6
 
 LANGUAGE  CONTAINED  IN  ANY  CLINICAL  CRITERIA RELIED UPON TO MAKE THE
 ADVERSE DETERMINATION AND A CLEAR EXPLANATION OF THE RATIONALE  SUPPORT-
 ING THE DETERMINATION THAT SUCH CLINICAL CRITERIA WERE DEEMED NOT SATIS-
 FIED;
   (ii)  instructions  on  how to initiate standard appeals and expedited
 appeals pursuant to section four  thousand  nine  hundred  four  and  an
 external  appeal pursuant to section four thousand nine hundred fourteen
 of this article;
   (iii) notice of the availability, upon request of the insured, or  the
 insured's  designee, of the clinical review criteria relied upon to make
 such determination. Such notice shall also specify what, if  any,  addi-
 tional  necessary  information  must be provided to, or obtained by, the
 utilization review agent in order to render a decision  on  the  appeal;
 [and]
   (iv)  for  an adverse determination related to a step therapy protocol
 override request, information that includes the clinical review criteria
 relied upon to make such determination and  any  applicable  alternative
 prescription  drugs subject to the step therapy protocol of the utiliza-
 tion review agent[.];
   (V) A STATEMENT SIGNED BY THE CLINICAL PEER  REVIEWER  THAT  MADE  THE
 ADVERSE DETERMINATION CONTAINING THE FOLLOWING INFORMATION:
   (A) THE FULL PRINTED NAME OF SUCH CLINICAL PEER REVIEWER;
   (B)  SUCH  CLINICAL  PEER  REVIEWER'S NATIONAL PROVIDER IDENTIFICATION
 NUMBER;
   (C) SUCH CLINICAL PEER REVIEWER'S  CREDENTIALS,  INCLUDING  ANY  BOARD
 CERTIFICATIONS  AND AREAS OF SPECIALTY EXPERTISE AND TRAINING, AS APPLI-
 CABLE;
   (D) THE TAXONOMY CODE OF SUCH CLINICAL PEER REVIEWER;
   (E) AN ATTESTATION BY SUCH CLINICAL PEER REVIEWER THAT THEY  HAVE  THE
 APPROPRIATE  TRAINING  AND  EXPERTISE  IN  THE FIELD OF MEDICINE THAT IS
 SUFFICIENT TO MAKE AN INFORMED DECISION REGARDING THE MEDICAL  NECESSITY
 OF  THE  HEALTH  CARE SERVICE OR SUPPLY BEING REQUESTED ON BEHALF OF THE
 INSURED AND THAT THEY HAVE NO CONFLICTS OF INTEREST THAT WOULD INTERFERE
 WITH THEIR ABILITY TO MAKE  AN  IMPARTIAL  DETERMINATION  BASED  ON  THE
 MERITS OF THE SPECIFIC PATIENT CASE;
   (F)  DOCUMENTATION  OF  THE AMOUNT OF TIME SUCH CLINICAL PEER REVIEWER
 SPENT EVALUATING THE MEDICAL RECORD OR OTHER INFORMATION RELATED TO  THE
 REVIEW BEFORE CONFIRMING THE ADVERSE DETERMINATION;
   (G)  AN  INDICATION  OF WHETHER SUCH CLINICAL PEER REVIEWER REVIEWED A
 PREPARED SUMMARY OF THE PATIENT'S MEDICAL RECORDS OR THE PATIENT'S ACTU-
 AL MEDICAL RECORDS IN MAKING THEIR ADVERSE DETERMINATION; AND
   (VI) A STATEMENT AS TO WHETHER AN ARTIFICIAL INTELLIGENCE-BASED  ALGO-
 RITHM,  AS SUCH TERM IS DEFINED BY SECTION THREE HUNDRED THIRTY-EIGHT OF
 THIS CHAPTER, WAS USED IN THE UTILIZATION REVIEW PROCESS,  AND  A  PLAIN
 LANGUAGE  EXPLANATION AS TO HOW SUCH ARTIFICIAL INTELLIGENCE-BASED ALGO-
 RITHM WAS EMPLOYED AND WHERE THE INSURED AND HEALTH  CARE  PROVIDER  CAN
 FIND MORE INFORMATION ABOUT THE SPECIFIC USAGE OF SUCH ARTIFICIAL INTEL-
 LIGENCE-BASED ALGORITHM.
   §  9.  Paragraph  (a)  of  subdivision 5 of section 4903 of the public
 health law, as amended by chapter 28 of the laws of 2024, is amended  to
 read as follows:
   (a)  Notice  of  an adverse determination made by a utilization review
 agent shall be in writing and must include:
   (i) the reasons for the determination including the  clinical  ration-
 ale,  if  any,  AND THE SPECIFIC COVERAGE OR CLINICAL CRITERIA THAT WERE
 NOT  SATISFIED,  INCLUDING  EXPLICIT  IDENTIFICATION  OF  THE   RELEVANT
 S. 10241                            7
 
 LANGUAGE  CONTAINED  IN  ANY  CLINICAL  CRITERIA RELIED UPON TO MAKE THE
 ADVERSE DETERMINATION AND A CLEAR EXPLANATION OF THE RATIONALE  SUPPORT-
 ING THE DETERMINATION THAT SUCH CLINICAL CRITERIA WERE DEEMED NOT SATIS-
 FIED;
   (ii)  instructions  on  how to initiate standard and expedited appeals
 pursuant to section forty-nine  hundred  four  and  an  external  appeal
 pursuant to section forty-nine hundred fourteen of this article;
   (iii) notice of the availability, upon request of the enrollee, or the
 enrollee's designee, of the clinical review criteria relied upon to make
 such  determination.  Such notice shall also specify what, if any, addi-
 tional necessary information must be provided to, or  obtained  by,  the
 utilization  review  agent  in order to render a decision on the appeal;
 [and]
   (iv) for an adverse determination related to a step  therapy  protocol
 override request, information that includes the clinical review criteria
 relied  upon  to  make such determination and any applicable alternative
 prescription drugs subject to the step therapy protocol of the  utiliza-
 tion review agent[.];
   (V)  A STATEMENT SIGNED BY THE PHYSICIAN WHO MADE THE ADVERSE DETERMI-
 NATION CONTAINING THE FOLLOWING INFORMATION:
   (A) THE FULL PRINTED NAME OF SUCH PHYSICIAN;
   (B) SUCH PHYSICIAN'S NATIONAL PROVIDER IDENTIFICATION NUMBER;
   (C) SUCH PHYSICIAN'S CREDENTIALS, INCLUDING ANY  BOARD  CERTIFICATIONS
 AND AREAS OF SPECIALTY EXPERTISE AND TRAINING, AS APPLICABLE;
   (D) THE TAXONOMY CODE OF SUCH PHYSICIAN;
   (E)  AN  ATTESTATION  BY SUCH PHYSICIAN THAT THEY HAVE THE APPROPRIATE
 TRAINING AND EXPERTISE IN THE FIELD OF MEDICINE THAT  IS  SUFFICIENT  TO
 MAKE  AN INFORMED DECISION REGARDING THE MEDICAL NECESSITY OF THE HEALTH
 CARE SERVICE OR SUPPLY BEING REQUESTED ON BEHALF OF THE INSURED AND THAT
 THEY HAVE NO CONFLICTS OF INTEREST THAT WOULD INTERFERE WITH THEIR ABIL-
 ITY TO MAKE AN IMPARTIAL  DETERMINATION  BASED  ON  THE  MERITS  OF  THE
 SPECIFIC PATIENT CASE;
   (F)  DOCUMENTATION OF THE AMOUNT OF TIME SUCH PHYSICIAN SPENT EVALUAT-
 ING THE MEDICAL RECORD OR OTHER INFORMATION RELATED TO THE REVIEW BEFORE
 CONFIRMING THE ADVERSE DETERMINATION;
   (G) AN INDICATION OF WHETHER SUCH PHYSICIAN REVIEWED A PREPARED SUMMA-
 RY OF THE PATIENT'S MEDICAL RECORDS  OR  THE  PATIENT'S  ACTUAL  MEDICAL
 RECORDS IN MAKING THEIR ADVERSE DETERMINATION; AND
   (VI)  A STATEMENT AS TO WHETHER AN ARTIFICIAL INTELLIGENCE-BASED ALGO-
 RITHM, AS SUCH TERM IS DEFINED BY SECTION THREE HUNDRED THIRTY-EIGHT  OF
 THIS  CHAPTER,  WAS  USED IN THE UTILIZATION REVIEW PROCESS, AND A PLAIN
 LANGUAGE EXPLANATION AS TO HOW SUCH ARTIFICIAL INTELLIGENCE-BASED  ALGO-
 RITHM  WAS  EMPLOYED  AND WHERE THE INSURED AND HEALTH CARE PROVIDER CAN
 FIND MORE INFORMATION ABOUT THE SPECIFIC USAGE OF SUCH ARTIFICIAL INTEL-
 LIGENCE-BASED ALGORITHM.
   § 10. This act shall take effect on the sixtieth day  after  it  shall
 have become a law. Effective immediately, the addition, amendment and/or
 repeal  of  any  rule  or regulation necessary for the implementation of
 this act on its effective date are authorized to be made  and  completed
 on or before such effective date.