HB 2175 — claims; prior authorization; conduct

HouseSenate Engrossed House Bill claims;

conduct State(now: of Arizona House of Representatives Fifty-seventh Legislature First Regular Session HOUSE BILL 2175 AN ACT AMENDING TITLE 20, CHAPTER 20, ARTICLE 1, ARIZONA REVISED STATUTES, BY ADDING SECTION 20-3103;

RELATINGprior TOauthorization; HEALTH CARE INSURANCE CLAIMS.

claims) State of Arizona House of Representatives Fifty-seventh Legislature First Regular Session CHAPTER 165 HOUSE BILL 2175 AN ACT AMENDING TITLE 20, CHAPTER 20, ARTICLE 1, ARIZONA REVISED STATUTES, BY ADDING SECTION 20-3103;

AMENDING TITLE 20, CHAPTER 26, ARTICLE 1, ARIZONA REVISED STATUTES, BY ADDING SECTION 20-3407;

RELATING TO INSURANCE.

Denial of claimsclaims; or prior authorization;

healthreview careof providerclaims review;BEFORE A HEALTH CARE INSURER MAY DENY A CLAIM THAT WAS SUBMITTED BY A PROVIDER ON THE BASIS OF MEDICAL NECESSITY, THE MEDICAL DIRECTOR SHALL INDIVIDUALLY REVIEW THE DENIAL.

unprofessionalDURING conduct;EACH INDIVIDUAL REVIEW, THE MEDICAL DIRECTOR SHALL EXERCISE INDEPENDENT MEDICAL JUDGMENT AND MAY NOT RELY SOLELY ON RECOMMENDATIONS FROM ANY OTHER SOURCE.

definitionSec. A.

ARTIFICIAL2. INTELLIGENCE MAY NOT BE USED TO DENY A CLAIM OR A PRIOR AUTHORIZATION FOR MEDICAL NECESSITY, EXPERIMENTAL STATUS OR ANY OTHER REASON THAT INVOLVES THE USE OF MEDICAL JUDGMENT.

B.Title 20, chapter 26, article 1, Arizona Revised Statutes, is amended by adding section 20-3407, to read:

A20-3407. HEALTH CARE PROVIDER SHALL INDIVIDUALLY REVIEW EACH CLAIM OR PRIOR AUTHORIZATION THAT INVOLVES MEDICAL NECESSITY, EXPERIMENTAL STATUS OR THAT REQUIRES THE USE OF MEDICAL JUDGMENT BEFORE A HEALTH CARE INSURER MAY DENY A CLAIM OR A PRIOR AUTHORIZATION.

C.Denial of prior authorization;

review of prior authorization BEFORE A HEALTH CARE PROVIDERINSURER THATMAY DENIESISSUE A CLAIMDIRECT ORDENIAL OF A PRIOR AUTHORIZATION WITHOUTOF ANA INDIVIDUALSERVICE REVIEWTHAT OFWAS THEREQUESTED CLAIMBY ORA PRIORPROVIDER AUTHORIZATIONAND COMMITSTHAT ANINVOLVES ACTMEDICAL OFNECESSITY, UNPROFESSIONALTHE CONDUCT.MEDICAL DIRECTOR SHALL INDIVIDUALLY REVIEW THE DENIAL.

D.DURING EACH INDIVIDUAL REVIEW, THE MEDICAL DIRECTOR SHALL EXERCISE INDEPENDENT MEDICAL JUDGMENT AND MAY NOT RELY SOLELY ON RECOMMENDATIONS FROM ANY OTHER SOURCE.

FORSec. THE PURPOSES OF THIS SECTION, "HEALTH CARE PROVIDER" MEANS A PERSON WHO IS CERTIFIED OR LICENSED PURSUANT TO TITLE 32, CHAPTER 7, 8, 11, 13, 14, 15, 15.1, 16, 17, 18, 19, 19.1, 21, 25, 28, 29, 33, 34, 35, 39, 41 OR 42, TITLE 36, CHAPTER 4, ARTICLE 6, TITLE 36, CHAPTER 6, ARTICLE 7 OR TITLE 36, CHAPTER 17 OR WHO HOLDS A SIMILAR LICENSE IN ANOTHER STATE.

3.

Effective date This act is effective from and after June 30, 2026.

APPROVED BY THE GOVERNOR MAY 12, 2025.

FILED IN THE OFFICE OF THE SECRETARY OF STATE MAY 12, 2025.