[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>