Protecting Patients from Automated Denials Act

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 9734 Introduced in House (IH)]

<DOC>

119th CONGRESS
  2d Session
                                H. R. 9734

     To amend title XVIII of the Social Security Act to establish
     requirements for the use of artificial intelligence in prior
       authorization denials by Medicare Advantage organizations.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                             July 16, 2026

Mr. Conaway (for himself and Mr. Murphy) introduced the following bill;
which was referred to the Committee on Ways and Means, and in addition
      to the Committee on Energy and Commerce, for a period to be
subsequently determined by the Speaker, in each case for consideration
  of such provisions as fall within the jurisdiction of the committee
                               concerned

_______________________________________________________________________

                                 A BILL

     To amend title XVIII of the Social Security Act to establish
     requirements for the use of artificial intelligence in prior
       authorization denials by Medicare Advantage organizations.

    Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Protecting Patients from Automated
Denials Act''.

SEC. 2. ESTABLISHING REQUIREMENTS FOR USE OF ARTIFICIAL INTELLIGENCE IN
              PRIOR AUTHORIZATION DENIALS UNDER MEDICARE ADVANTAGE.

    (a) In General.--Section 1852 of the Social Security Act (42 U.S.C.
1395w-22) is amended by adding at the end the following new subsection:
    ``(o) Requirements for Use of Artificial Intelligence in Prior
Authorization Denials.--
            ``(1) In general.--With respect to plan years beginning on
        or after January 1, 2027, an MA plan that imposes a prior
        authorization requirement with respect to an item or service
        for which benefits are available under such plan may not deny a
        request for prior authorization with respect to such item or
        service based on the output of artificial intelligence, unless
        the following requirements are met:
                    ``(A) Before such denial is issued, such denial is
                reviewed and approved, under the clinical direction of
                a medical director of such MA plan, by a qualified
                physician reviewer.
                    ``(B) Such qualified physician reviewer provides to
                such MA plan a signed attestation that, in reviewing
                and approving such denial--
                            ``(i) such qualified physician reviewer
                        exercised medical judgment that was independent
                        from such output;
                            ``(ii) such denial was not generated or
                        dictated by artificial intelligence; and
                            ``(iii) any software used in preparing such
                        denial was used only for administrative
                        purposes.
                    ``(C) Such MA plan provides to the provider who
                submitted such request--
                            ``(i) a copy of the signed attestation
                        described in subparagraph (B);
                            ``(ii) an opportunity to communicate
                        directly with such qualified physician
                        reviewer; and
                            ``(iii) an opportunity to discuss with such
                        qualified physician reviewer the proposed
                        individualized clinical basis for such denial.
                    ``(D) Such MA plan discloses to the individual to
                whom such denial is issued and to such provider--
                            ``(i) that artificial intelligence was used
                        as part of such denial; and
                            ``(ii) the National Provider Identifier
                        number of such qualified physician reviewer.
                    ``(E) Such MA plan makes, and maintains for not
                less than 10 years after the date on which such denial
                is issued, records with respect to such denial about--
                            ``(i) the use of artificial intelligence;
                            ``(ii) the review and approval by such
                        qualified physician reviewer under subparagraph
                        (A); and
                            ``(iii) information provided under
                        subparagraph (C), including a copy of the
                        signed attestation described in subparagraph
                        (B).
            ``(2) Report to secretary.--Not later than March 31, 2027,
        and every 90 days thereafter, an MA plan that imposes a prior
        authorization requirement with respect to an item or service
        for which benefits are available under such plan shall submit
        to the Secretary a report that includes, with respect to the
        most recent 90-day period for which such data is available,
        information with respect to any requests for prior
        authorization for such an item or service that were denied
        based on the output of artificial intelligence, including--
                    ``(A) any signed attestations provided under
                paragraph (1)(B); and
                    ``(B) any algorithm, decision protocol, or
                documentation associated with such output.
            ``(3) Oversight authority.--In the case of an MA plan that
        imposes a prior authorization requirement with respect to an
        item or service for which benefits are available under such
        plan, the Secretary may audit and inspect any use of artificial
        intelligence by such plan that is associated with such
        requirement, including by--
                    ``(A) reviewing data related to denials of requests
                for prior authorization;
                    ``(B) examining whether qualified physician
                reviewers provided signed attestations under paragraph
                (1)(B);
                    ``(C) reviewing such signed attestations;
                    ``(D) comparing outputs of artificial intelligence
                to denials of requests for prior authorization;
                    ``(E) assessing the rates of such denials that were
                overturned or did not satisfy the requirements of
                paragraph (1);
                    ``(F) reviewing internal policies;
                    ``(G) interviewing employees; and
                    ``(H) reviewing any algorithm, decision protocol,
                or documentation related to such use.
            ``(4) Definitions.--In this subsection:
                    ``(A) Artificial intelligence.--The term
                `artificial intelligence' has the meaning given such
                term in section 5002 of the National Artificial
                Intelligence Initiative Act of 2020 (15 U.S.C. 9401)
                and includes technology that--
                            ``(i) produces synthetic content in
                        response to prompts using patterns learned from
                        data;
                            ``(ii) acts with autonomy and purpose by
                        executing tasks proactively and independently
                        with minimal or no human intervention; and
                            ``(iii) interfaces with external systems
                        and tools to take meaningful action, make
                        decisions, set goals, and operate beyond
                        initial training data.
                    ``(B) Qualified physician reviewer.--The term
                `qualified physician reviewer' means, with respect to
                an item or service for which a request for prior
                authorization is submitted to an MA plan, a physician
                who--
                            ``(i) possesses a current and valid non-
                        restricted license to practice medicine in the
                        State where such item or service will be
                        furnished;
                            ``(ii) is board-certified or eligible under
                        the rules and guidelines of the American Board
                        of Medical Specialties or American Osteopathic
                        Association in a specialty that correlates with
                        the specialty of the provider who submitted
                        such request; and
                            ``(iii) has experience practicing in such
                        specialty.''.
    (b) Promulgation of Regulations.--Not later than 1 year after the
date of the enactment of this section, the Secretary shall issue a
final rule to carry out the amendments made by this section.
                                 <all>