Adverse determination
A decision by an insurer or review agent to deny, reduce, or terminate coverage for a healthcare service.
How the laws define this
Both legal texts agree that an adverse determination fundamentally consists of a decision to deny, reduce, or terminate an individual's requested healthcare service or insurance coverage. Their primary divergence lies in the decision-making entity, the scope of affected actions, and the required qualifications of the reviewer. An Act amending Chapter 46 of Title 33 of the Official Code of Georgia Annotated focuses on decisions made by private review agents or utilization review entities based on medical necessity or appropriateness, specifically addressing insurance coverage and prohibiting sole reliance on artificial intelligence systems. In contrast, the Ensuring Transparency in Prior Authorization Act explicitly incorporates denials, reductions, or terminations of payment alongside healthcare services, while establishing a specific operational requirement that these determinations must be made directly by qualified physicians or clinical peers. Thus, the Georgia enactment centers on regulating review entities and automated tools, whereas the Ensuring Transparency in Prior Authorization Act focuses on mandatory professional credentials for decision-makers.
Synthesised from the 2 statutory definitions below. Each one is quoted in full, with its source.
How jurisdictions differ
What is distinctive in each definition, binding law in force first.
| Jurisdiction | Instrument | Status | What is distinctive |
|---|---|---|---|
| Nebraska, United States | Adopt the Ensuring Transparency in Prior Authorization Act and provide for insurance and medicaid coverage of biomarker testing | In Force | Adds that the denial, reduction, or termination must be made by qualified physicians or clinical peers. |
| Georgia, United States | AN ACT To amend Chapter 46 of Title 33 of the Official Code of Georgia Annotated, relating to certification of private review agents, so as to provide that certain decisions with regard to the provision of insurance coverage for healthcare services shall not be based solely on artificial intelligence systems, artificial intelligence, or other software tools; to provide for definitions; to provide for related matters; to provide for an effective date; to repeal conflicting laws; and for other purposes. | Awaiting Entry | Specifies that the decision is made by a private review agent or utilization review entity based on medical necessity or appropriateness. |
What it triggers
- In Nebraska, under the Ensuring Transparency in Prior Authorization Act, an adverse determination must be made by qualified physicians or clinical peers.source
- In Georgia, under SB 444, an adverse determination by private review agents shall not be based solely on artificial intelligence systems.source
Definitions (2)
An adverse determination refers to a decision made by a private review agent or utilization review entity to deny, reduce, or terminate an insured's coverage for a healthcare service, based on a review of medical necessity or appropriateness.
Refers to a denial, reduction, or termination of a requested healthcare service or payment, which, under the Act, must be made by qualified physicians or clinical peers.
Questions and answers
Who must make an adverse determination in Nebraska?
Under the Nebraska Act, adverse determinations must be made by qualified physicians or clinical peers. Health insurers and Medicaid providers cannot use AI as the sole basis.
What do Georgia's rules say about AI in adverse determinations?
Georgia SB 444 prohibits private review agents from basing adverse determinations solely on AI or other software tools. It requires human clinical peer review for denials.
How do Nebraska and Georgia define adverse determinations differently?
Nebraska emphasizes decisions by qualified physicians or peers, while Georgia focuses on decisions by review agents assessing medical necessity.