SB 794 — Mandatory Human Reviews of Insurance Claim Denials

Florida Senate - 2025 CS for SB 794 By Senatorthe BradleyCommittee 6-01155-25on 2025794__Banking Aand billInsurance; to be entitled An act relating to mandatory human reviews of insurance claim denials;

and Senator Bradley 597-02813-25 2025794c1 A bill to be entitled An act relating to mandatory human reviews of insurance claim denials;

defining theterms; term “qualified human professional”;

requiring that insurers’ decisions to deny claims toor beany reviewed,portion approved,of anda signedclaim offbe onmade by qualified human professionals;

prohibitingspecifying artificial intelligence, machine learning algorithms, and automated systems from serving as the basisduties forof denyingqualified claims;human professionals;

requiring insurersan insurer to maintain certain recordsrecords; of the human review process for denied claims;

prohibiting using algorithms, artificial intelligence, or machine learning systems as the sole basis for determining whether to adjust or deny a claim;

providingrequiring reportingthat requirements;certain insurers detail certain information in their claims handling manual;

authorizing the Office of Insurance Regulation to auditconduct claimmarket denials;conduct examinations and investigations under certain circumstances;

authorizing the Financial Services Commission to adopt rules;

627.4263 Mandatory human reviews of claim denials.— (1) As used in this section, the termterm: “qualified human professional” includes, but is not limited to, a supervisor, a claims manager, or a licensed claims adjuster having authority over a claim.

(2)(a)(a) An“Algorithm” insurer’smeans decision to deny a claimclearly mustspecified bemathematical reviewed,process approved,for andcomputation signedwhich offuses onrules bydesigned ato qualifiedgive humanprescribed professional.results.

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Florida Senate - 2025 CS for SB 794 6-01155-25597-02813-25 2025794__2025794c1 (b) Artificial“Artificial intelligence,intelligence system” means a machinemachine-based learningsystem algorithm,that ormay anhave automatedvarying systemlevels mayof notautonomy serveand that can, for a given set of objectives, generate outputs, such as thepredictions, basisrecommendations, foror determiningcontent, whetherinfluencing todecisions denymade ain claim.real or virtual environments.

(3)(c) An“Machine insurerlearning shallsystem” maintainmeans detailedan recordsartificial ofintelligence thesystem humanthat reviewhas processthe describedability into paragraphlearn (2)(a)from forprovided alldata deniedwithout claims,being including:explicitly programmed.

(a)(d) The“Qualified namehuman andprofessional” titlemeans ofan theindividual qualifiedwho, humanunder professionalthe whoFlorida reviewedInsurance Code, has the denialauthority decision.to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.

(b)(2) TheAn dateinsurer’s anddecision timeto deny a claim or any portion of thea reviewclaim must be made by thea qualified human professional.

(c)(3) DocumentationA ofqualified thehuman basisprofessional forshall, thebefore denial,determining includingwhether anyto supplementaladjust informationor provideddeny bya automatedclaim tools.or a portion of a claim, do all of the following:

(4)(a) InAnalyze allthe denialfacts communicationsof tothe aclaim claimant,and anthe insurerterms shall:of the insurance policy independently of any system or algorithm.

(a)(b) ClearlyReview identify the qualifiedaccuracy humanof professionalany whooutput reviewedgenerated theby denialsuch decision.a system or algorithm.

(b)(c) IncludeConduct aany statementreview affirmingof that artificial intelligence, a machineclaim learningadjustment algorithm, or anclaim automateddecision systemthat didwas notmade serveby asanother thequalified basishuman forprofessional. determining whether to deny the claim.

(5)(4) An insurer shall submitmaintain periodicdetailed compliancerecords reportsof to the officeactions detailingof thequalified stepshuman takenprofessionals who are required to complyperform withthe thisactions section.under subsection (3), including:

(6)(a) The officename mayand audittitle claimof denialsthe qualified human professional who made the decision to verifydeny compliancea withclaim thisor section.a portion of a claim and of any qualified human professional who reviewed a claim Page 2 of 4 CODING:

SectionWords 2.stricken are deletions;

Thiswords actunderlined shallare takeadditions. effect July 1, 2025.

PageFlorida 2Senate of- 22025 CODING:CS for SB 794 597-02813-25 2025794c1 adjustment or claim decision.

(b) The date and time of the claim decision and of any review of the claim adjustment.

(c) Documentation of the basis for the denial of the claim or a portion of the claim, including any information provided by an algorithm, an artificial intelligence system, or a machine learning system.

(5) An algorithm, an artificial intelligence system, or a machine learning system may not serve as the sole basis for determining whether to adjust or deny a claim.

(6) In all denial communications to a claimant, an insurer shall:

(a) Clearly identify the qualified human professional who made the decision to deny the claim or a portion of the claim;

and (b) Include a statement affirming that an algorithm, an artificial intelligence system, or a machine learning system did not serve as the sole basis for determining whether to deny the claim or a portion of the claim.

(7) An insurer that uses an algorithm, an artificial intelligence system, or a machine learning system as part of its claims handling process shall detail in its claims handling manual the manner in which such systems are to be used and the manner in which the insurer complies with this section.

(8) The office may conduct market conduct examinations and investigations or use any method it deems necessary to verify compliance with this section.

(9) The commission may adopt rules to implement this section.

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Words stricken are deletions;

words underlined are additions.

Florida Senate - 2025 CS for SB 794 597-02813-25 2025794c1 Section 2.

This act shall take effect January 1, 2026.