1| STATE OF OKLAHOMA |
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2| 2nd Session of the 60th Legislature (2026) |
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3|SENATE BILL 1967 By: Mann |
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6| AS INTRODUCED |
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7| An Act relating to the Hospital and Medical Services |
| Utilization Review Act; amending 36 O.S. 2021, |
8| Section 6552, which relates to definitions; defining |
| terms; requiring certain utilization review |
9| organization or insurer that uses certain artificial |
| intelligence tool to adhere to certain requirements; |
10| prohibiting certain tool to deny, delay, or modify |
| certain services; requiring certain determinations to |
11| be made by certain licensed professional; requiring |
| certain health benefit plan to notify certain |
12| enrollees about use of certain tools; requiring |
| health benefit plan to submit certain tools to the |
13| Insurance Commissioner; requiring Commissioner to |
| implement certain processes; requiring certain |
14| clinical peer reviewer to document certain |
| utilization review; providing for certain fines and |
15| fees; requiring Commissioner to promulgate rules and |
| regulations; providing for codification; and |
16| providing an effective date. |
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18| |
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19|BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA: |
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20| SECTION 1. AMENDATORY 36 O.S. 2021, Section 6552, is |
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21|amended to read as follows: |
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22| Section 6552. As used in the Hospital and Medical Services |
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23|Utilization Review Act: |
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Req. No. 2293 Page 1
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1| 1. "Utilization review" means a system for prospectively, |
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2|concurrently and retrospectively reviewing the appropriate and |
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3|efficient allocation of hospital resources and medical services |
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4|given or proposed to be given to a patient or group of patients. It |
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5|does not include an insurer's normal claim review process to |
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6|determine compliance with the specific terms and conditions of the |
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7|insurance policy |
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8| "Artificial intelligence" means a computer system, program, or |
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9|set of algorithms capable of performing tasks on producing outposts |
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10|that imitate intelligent human behaviors; |
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11| 2. "Private review agent" means a person or entity who performs |
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12|utilization review on behalf of: |
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13| a. an employer in this state, or |
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14| b. a third party that provides or administers hospital |
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15| and medical benefits to citizens of this state, |
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16| including, but not limited to: |
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17| (1) a health maintenance organization issued a |
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18| license pursuant to Section 2501 et seq. of Title |
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19| 63 of the Oklahoma Statutes, unless the health |
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20| maintenance organization is federally regulated |
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21| and licensed and has on file with the Insurance |
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22| Commissioner a plan of utilization review carried |
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23| out by health care professionals and providing |
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Req. No. 2293 Page 2
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1| for complaint and appellate procedures for |
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2| claims, or |
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3| (2) a health insurer, not-for-profit hospital service |
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4| or medical plan, health insurance service |
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5| organization, or preferred provider organization |
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6| or other entity offering health insurance |
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7| policies, contracts or benefits in this state"Utilization review plan" means a description of utilization |
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12|review procedures; |
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13| 4. "Commissioner" means the Insurance Commissioner; |
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14| 5. 4. "Certificate" means a certificate of registration granted |
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15|by the Insurance Commissioner to a private review agent; and |
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16| 6. 5. "Health care provider" means any person, firm, |
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17|corporation or other legal entity that is licensed, certified, or |
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18|otherwise authorized by the laws of this state to provide health |
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19|care services, procedures or supplies in the ordinary course of |
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20|business or practice of a profession; |
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21| 6. "Private review agent" means a person or entity that |
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22|performs utilization review on behalf of: |
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23| a. an employer in this state, or |
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Req. No. 2293 Page 3
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1| b. a third party that provides or administers hospital |
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2| and medical benefits to citizens of this state, |
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3| including, but not limited to: |
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4| (1) a health maintenance organization issued a |
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5| license pursuant to Section 6901 et seq. of this |
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6| title, unless the health maintenance organization |
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7| is federally regulated and licensed and has on |
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8| file with the Insurance Commissioner a plan of |
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9| utilization review carried out by health care |
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10| professionals and providing for complaint and |
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11| appellate procedures for claims, or |
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12| (2) a health insurer, not-for-profit hospital service |
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13| or medical plan, health insurance service |
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14| organization, or preferred provider organization |
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15| or other entity offering health insurance |
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16| policies, contracts or benefits in this state; |
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17| 7. "Utilization review" means a system for prospectively, |
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18|concurrently, and retrospectively reviewing the allocation of |
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19|hospital resources and medical services given or proposed to be |
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20|given to a patient or group of patients. It does not include an |
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21|insurer's normal claim review process to determine compliance with |
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22|the specific terms and conditions of the insurance policy; |
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23| 8. "Utilization review plan" means a description of utilization |
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24|review procedures; and |
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Req. No. 2293 Page 4
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1| 9. "Utilization review organization" means the same as defined |
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2|in Section 6475.3 of this title. |
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3| SECTION 2. NEW LAW A new section of law to be codified |
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4|in the Oklahoma Statutes as Section 6567 of Title 36, unless there |
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5|is created a duplication in numbering, reads as follows: |
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6| A. A utilization review organization, disability insurer, or |
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7|specialized health insurer that uses an artificial intelligence tool |
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8|or contracts with or otherwise works through an entity that uses an |
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9|artificial intelligence tool shall ensure that the artificial |
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10|intelligence tool: |
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11| 1. Bases its determination on the following information, as |
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12|applicable: |
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13| a. an enrollee's medical or other clinical history, |
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14| b. individual clinical circumstances as presented by the |
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15| requesting provider, and |
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16| c. other relevant clinical information contained in the |
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17| enrollee's medical or other clinical record; |
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18| 2. Does not base its determination solely on a group dataset; |
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19| 3. Does not supplant health care provider decision-making; |
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20| 4. Does not discriminate against enrollees in violation of |
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21|state and federal law; |
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22| 5. Does not use patient data beyond its intended and stated |
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23|purpose consistent with the federal Health Insurance Portability and |
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24|Accountability Act of 1996, P.L. No. 104-191, as applicable; |
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Req. No. 2293 Page 5
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1| 6. Does not cause harm to the enrollee; |
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2| 7. Is applied in accordance with any applicable regulations and |
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3|guidance issued by the federal Department of Health and Human |
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4|Services; |
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5| 8. Is open to inspection for audit or compliance review by the |
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6|Insurance Commissioner; |
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7| 9. Contains disclosures pertaining to the use and oversight of |
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8|the artificial intelligence tool in the written policies and |
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9|procedures; and |
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10| 10. Requires performance use and outcomes to be periodically |
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11|reviewed and revised to maximize accuracy and reliability. |
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12| B. The artificial intelligence tool shall not deny, delay, or |
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13|modify health care services based, in whole or in part, on medical |
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14|necessity. A determination of medical necessity shall be made only |
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15|by a licensed physician or a licensed health care professional |
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16|competent to evaluate the specific clinical issues involved in the |
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17|health care services requested by the provider, by reviewing and |
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18|considering the requesting provider's recommendation, the enrollee's |
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19|medical or other clinical history, and individual circumstances. |
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20| C. Any health benefit plan in this state shall notify enrollees |
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21|and insureds about the use or lack of use of artificial intelligence |
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22|tools in the utilization review process on the accessible Internet |
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23|website of such health benefit plan. |
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Req. No. 2293 Page 6
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1| D. A clinical peer reviewer who participates in a utilization |
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2|review process for a health benefit plan that initially uses |
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3|artificial intelligence tools for a utilization review shall open |
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4|and document the utilization review of the individual clinical |
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5|records or data prior to issuing an adverse determination. |
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6| E. A violation of this act by a health benefit plan or clinical |
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7|peer reviewer shall be subject to one or more of the following |
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8|penalties, not to exceed in aggregate Five Hundred Thousand Dollars |
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9|($500,000.00) for a health benefit plan or One Hundred Thousand |
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10|Dollars ($100,000.00) for a clinical peer reviewer, in a calendar |
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11|year: |
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12| 1. Suspension or revocation of a license; |
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13| 2. Refusal, for a period not to exceed one (1) year, to issue a |
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14|new license; or |
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15| 3. A fine not more than Ten Thousand Dollars ($10,000.00) for |
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16|each willful violation. |
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17| F. Penalties pursuant to this act shall be in addition to any |
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18|other remedies or penalties that may be imposed under any other |
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19|applicable state or federal law. |
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20| G. This act shall apply to utilization review or utilization |
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21|management functions that prospectively, concurrently, |
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22|retrospectively review requests for covered health care services. |
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23| H. The Commissioner may promulgate rules and regulations |
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24|pursuant to the provisions of this act. |
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Req. No. 2293 Page 7
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1| SECTION 3. This act shall become effective November 1, 2026. |
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3| 60-2-2293 CAD 1/15/2026 10:42:58 AM |
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Req. No. 2293 Page 8
