| 12 | 13 | | A BILL TO BE ENTITLED 1 |
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| 13 | 14 | | AN ACT TO ENSURE THAT HEALTH BENEFIT PLAN DETERMINATIONS OF THE 2 |
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| 14 | 15 | | MEDICAL NECESSITY OR APPROPRIATENESS OF HEALTHCARE SERVICE S 3 |
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| 15 | 16 | | CONTINUE TO BE MADE BY LICENSED AND QUALIFIED HEALTHCARE 4 |
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| 16 | 17 | | PROVIDERS. 5 |
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| 17 | 18 | | The General Assembly of North Carolina enacts: 6 |
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| 18 | 19 | | SECTION 1. G.S. 58-50-61 reads as rewritten: 7 |
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| 19 | 20 | | "§ 58-50-61. Utilization review. 8 |
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| 20 | 21 | | … 9 |
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| 21 | 22 | | (o) Violation. – A In accordance with this Chapter, a violation of this section subjects an 10 |
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| 22 | 23 | | insurer and an agent of the insurer to G.S. 58-2-70. 11 |
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| 23 | 24 | | (p) Reserved for future codification purposes. 12 |
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| 24 | 25 | | (q) Reserved for future codification purposes. 13 |
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| 25 | 26 | | (r) Reserved for future codification purposes. 14 |
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| 26 | 27 | | (s) Artificial Intelligence. – An insurer shall not use an artificial intelligence-based 15 |
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| 27 | 28 | | algorithm as the sole basis for a utilization review determination to, in whole or in part, deny, 16 |
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| 28 | 29 | | delay, or modify any healthcare services for an insured. Only individuals meeting the licensing 17 |
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| 29 | 30 | | and qualification requirements for participating in the utilization review process under this 18 |
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| 30 | 31 | | section shall make a determination regarding the medical necessity or appropriateness of any 19 |
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| 31 | 32 | | healthcare service. Insurers shall verify that all contracts with a third party, including with a 20 |
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| 32 | 33 | | pharmacy benefits manager, for conducting any utilization review are not in violation of this 21 |
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| 33 | 34 | | subsection." 22 |
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| 34 | 35 | | SECTION 2. In accordance with G.S. 135-48.24(b) and G.S. 135-48.30(a)(7) which 23 |
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| 35 | 36 | | require the State Treasurer to implement procedures that are substantially similar to the 24 |
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| 36 | 37 | | provisions of G.S. 58-50-61 for the North Carolina State Health Plan for Teachers and State 25 |
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| 37 | 38 | | Employees (State Health Plan), the State Treasurer and the Executive Administrator of the State 26 |
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| 38 | 39 | | Health Plan shall review all practices of the State Health Plan and all contracts with, and practices 27 |
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| 39 | 40 | | of, any third party conducting any utilization review on behalf of the State Health Plan to ensure 28 |
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| 40 | 41 | | compliance with G.S. 58-50-61(s), as amended by Section 1 of this act. 29 |
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| 41 | 42 | | SECTION 3. This act is effective 30 days after it becomes law. 30 |
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