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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
7 Utilization Review Act; amending 36 O.S. 2021,
8 Section 6552, which relates to definitions; defining
8 terms; requiring certain utilization review
9 organization or insurer that uses certain artificial
9 intelligence tool to adhere to certain requirements;
10 prohibiting certain tool to deny, delay, or modify
10 certain services; requiring certain determinations to
11 be made by certain licensed professional; requiring
11 certain health benefit plan to notify certain
12 enrollees about use of certain tools; requiring
12 health benefit plan to submit certain tools to the
13 Insurance Commissioner; requiring Commissioner to
13 implement certain processes; requiring certain
14 clinical peer reviewer to document certain
14 utilization review; providing for certain fines and
15 fees; requiring Commissioner to promulgate rules and
15 regulations; providing for codification; and
16 providing an effective date.
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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
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
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
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8 "Artificial intelligence tool" means a tool that uses an
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9 artificial intelligence or algorithm for the purpose of utilization
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10 review based in whole or in part on medical necessity;
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11 3. "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
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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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
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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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
1 SECTION 3. This act shall become effective November 1, 2026.
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3 60-2-2293 CAD 1/15/2026 9:15:11 AM
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Req. No. 2293 Page 8Every fact on this page links to its source, starting with the official bill record.