Privacy Law Library

Health insurance utilization review: use of artificial intelligence

MD AI Utilization Review Law

Artificial intelligence · Health

Enacted by 2025 Md. Laws ch. 747 (HB 820), this law sets guardrails on AI and algorithms used by health insurers and their review agents to decide whether care is medically necessary. Tools must rely on the individual patient's clinical information rather than group data alone, may not deny, delay, or modify care, must not discriminate, must be auditable by the Commissioner, and may not use patient data beyond its stated purpose. Carriers must also report whether AI was used in adverse decisions.

Where
Maryland
Citation
Md. Code, Ins. §§ 15-10B-05.1, 15-10A-06
Status
In force
In force since
2025-10-01
Enforced by
Maryland Insurance Commissioner
People can sue
No
Penalties
Enforced by the Insurance Commissioner under the Insurance Article's general enforcement provisions (penalties not separately specified in the section).
Applies to
  • Health insurers, nonprofit health service plans, HMOs, dental plan organizations, and other state-regulated health benefit plan providers that use, or contract with entities that use, AI, algorithms, or software tools for utilization review (15-10B-05.1(a)-(b))
  • Pharmacy benefits managers and private review agents conducting AI-assisted utilization review for carriers (15-10B-05.1(b)(2))

What a privacy notice must say

  • Report to the Commissioner the number of adverse decisions and whether AI, an algorithm, or other software was used in making them.Ins. 15-10A-06

Practices it requires

  • Ensure AI, algorithm, or software tools base utilization review determinations on the enrollee's own medical or clinical history and circumstances, not solely on group datasets.Ins. 15-10B-05.1(c)(1)-(2)
  • An AI, algorithm, or software tool may not deny, delay, or modify health care services, or replace the health care provider's role in determinations.Ins. 15-10B-05.1(c)(4), (d)
  • Do not use patient data beyond its intended and stated purpose, consistent with HIPAA.Ins. 15-10B-05.1(c)(10)

Other duties

  • Ensure the tool does not result in unfair discrimination, is open to inspection by the Commissioner, is described with oversight policies in the utilization plan, and is reviewed at least quarterly.Ins. 15-10B-05.1(c)(5)-(9)

Sources

Checked against these sources on 2026-09-25 by research agent (Claude), primary sources.

Unverified: The subsection of 15-10A-06 containing the AI reporting item and the reporting frequency were not confirmed.

Research reference, not legal advice.