Private Review Agent
An entity certified to conduct utilization review for healthcare services coverage.
How the laws define this
Both authorities agree that a private review agent is an entity that performs utilization reviews to evaluate healthcare services for insurance coverage. The principal distinction lies in how each source specifies the agent's scope, requirements, and structural context. Under Chapter 46 of Title 33 of the Official Code of Georgia Annotated, private review agents are explicitly tasked with assessing the medical necessity and appropriateness of healthcare services, and the associated law mandates that coverage decisions cannot be based solely on artificial intelligence systems, artificial intelligence, or other software tools. In contrast, the instrument titled Health Insurance – Utilization Review – Use of Artificial Intelligence defines a private review agent strictly by its functional relationship, identifying it as an entity that performs utilization review for a carrier or PBM. Thus, Georgia emphasizes substantive evaluation standards and rules against fully automated AI decision-making, whereas the second instrument focuses on service for carriers or PBMs.
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 |
|---|---|---|---|
| Maryland, United States | Health Insurance – Utilization Review – Use of Artificial Intelligence | In Force | This definition widens the term to explicitly include entities performing utilization review for PBMs in addition to carriers. |
| 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 | This definition limits the term to entities defined in Georgia's Chapter 46 of Title 33, emphasizing assessment of medical necessity and appropriateness for coverage. |
What it triggers
- In Maryland, under HB 820, these entities are prohibited from using AI to deny care and must ensure human oversight and patient-specific decisions.source
- In Georgia, under SB 444, private review agents must not base adverse coverage decisions solely on AI and require qualified human clinical peers to review denials.source
Definitions (2)
Private review agents are entities, as defined in Chapter 46 of Title 33 of the Official Code of Georgia Annotated, responsible for assessing the medical necessity and appropriateness of healthcare services for insurance purposes. They conduct utilization reviews to determine coverage.
An entity that performs utilization review for a carrier or PBM.
Questions and answers
What restrictions apply to private review agents using AI in Maryland?
Maryland HB 820 prohibits AI from denying care and mandates human oversight with patient-specific decisions by these entities.
Can Georgia private review agents deny coverage based only on AI?
Georgia SB 444 prohibits health insurers and review agents from making adverse coverage decisions based solely on AI. It requires qualified human clinical peers to review and approve any coverage denials.
How do Maryland and Georgia define private review agents differently?
Maryland defines them as entities performing utilization review for carriers or PBMs. Georgia limits them to entities in Chapter 46 of Title 33 assessing medical necessity for insurance coverage.