| Physician-only determinations | Only licensed physicians or qualified professionals may deny, delay, or modify services based on medical necessity — AI cannot make these calls |
| Clinical basis | AI tools must base utilization review determinations on enrollee clinical history, provider circumstances, and medical records |
| Non-supplanting | AI must not supplant provider decision-making in utilization review |
| Non-discrimination | AI must be equitably applied and not discriminate |
| Auditability | AI tools used for UR/UM must be auditable |
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