Downcoding of Health Benefits Claims (AI use limits and disclosure)

Enacted by HEA 1271 (2026) and effective July 1, 2026, this chapter limits claim downcoding by health insurers. Insurers may not use automated tools, including AI, as the sole basis for a medical-necessity downcode without human review of the medical record. Providers may not submit claims generated by automated tools without human review. Insurers must disclose when AI is used to deny prior authorization or downcode a claim.