AB50,1394,9 601.455 Fair claims processing, health insurance transparency, and claim denial rate audits. (1) Definitions. In this section:

AB50,1394,15 (a) “Claim denial” means the refusal by an insurer to provide payment under a disability insurance policy for a service, treatment, or medication recommended by a health care provider. “Claim denial” includes the prospective refusal to pay for a service, treatment, or medication when a disability insurance policy requires advance approval before a prescribed medical service, treatment, or medication is provided.

AB50,1394,16 (b) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

AB50,1394,17 (c) “Health care provider” has the meaning given in s. 146.81 (1) (a) to (p).

AB50,1394,20 (2) Claims processing. (a) Insurers shall process each claim for a disability insurance policy within a time frame that is reasonable and prevents an undue delay in an insured’s care, taking into account the medical urgency of the claim.

AB50,1394,24 (b) If an insurer determines additional information is needed to process a claim for a disability insurance policy, the insurer shall request the information from the insured within 5 business days of making the determination and shall provide at least 15 days for the insured to respond.

AB50,1395,1 (c) All claim denials shall include all of the following:

AB50,1395,3 1. A specific and detailed explanation of the reason for the denial that cites the exact medical or policy basis for the denial.

AB50,1395,6 2. A copy of or a publicly accessible link to any policy, coverage rules, clinical guidelines, or medical evidence relied upon in making the denial decision, with specific citation to the provision justifying the denial.

AB50,1395,9 3. Additional documentation, medical rationale, or criteria that must be met or provided for approval of the claim, including alternative options available under the policy.

AB50,1395,12 (d) If an insurer uses artificial intelligence or algorithmic decision-making in processing a claim for a disability insurance policy, the insurer must notify the insured in writing of that fact. The notice shall include all of the following:

AB50,1395,15 1. A disclosure that artificial intelligence or algorithmic decision-making was used at any stage in reviewing the claim, even if a human later reviewed the outcome.

AB50,1395,18 2. A detailed explanation of how the artificial intelligence or algorithmic decision-making reached its decision, including any factors the artificial intelligence or algorithmic decision-making weighed.

AB50,1395,20 3. A contact point for requesting a human review of the claim if the claim was denied.

AB50,1395,23 (3) Independent review of denials. In addition to an insured’s right to an independent review under s. 632.835, as applicable, insureds have the right to request a review by the office of the public intervenor of any claim denial.

AB50,1396,2 (4) Prohibited practices. An insurer may not do any of the following with respect to a disability insurance policy:

AB50,1396,3 (a) Use vague or misleading policy terms to justify a claim denial.

AB50,1396,4 (b) Fail to provide a specific and comprehensible reason for a claim denial.

AB50,1396,6 (c) Cancel coverage under the policy after a claim is submitted due to alleged misstatements on the policy application.

AB50,1396,8 (d) Deny a claim based on hidden or ambiguous exclusions in a disability insurance policy.

AB50,1396,9 (e) Stall review of a claim to avoid timely payment.

AB50,1396,11 (f) Reject a claim without reviewing all relevant medical records or consulting qualified experts.

AB50,1396,13 (g) Fail to properly review or respond to an insured’s appeal in a timely manner.

AB50,1396,15 (h) Allow non-physician personnel to determine whether care is medically necessary.

AB50,1396,17 (i) Apply different medical necessity criteria based on financial interests rather than patient needs.

AB50,1396,19 (j) Disregard a treating health care provider’s medical assessment without a valid clinical reason.

AB50,1396,21 (k) Mandate prior approval for routine or urgent procedures in a manner that causes harmful delays.

AB50,1396,24 (L) For a disability insurance policy that provides coverage of emergency medical services, refuse to cover emergency medical services provided by out-of- network providers.

AB50,1397,2 (m) List a health care provider as in-network on a provider directory and then deny a claim by stating the health care provider is out-of-network.