24-1313 Delegated PPGs: Follow Requirements for Use of AI in Utilization Review and Management
Date: 12/19/24
Requirements are effective as of January 1, 2025
California Senate Bill (SB) 1120 requires the Plan and contracted entities, such as delegated participating physician groups (PPGs), that use artificial intelligence (AI) or other specified software tools for utilization review (UR) or utilization management (UM) to comply with specified requirements. The tool must base its determinations on specified information and apply its use fairly and equitably.
How this bill affects you
Per SB 1120, PPGs delegated for UR or UM must comply with requirements around use of AI and UR/UM including, but not limited to, the following. Such delegated PPGs must:
- Have written policies and procedures that set forth the process by which they conduct prospective, retrospective or concurrent reviews and approve, modify, delay or deny requests for services. The policies and procedures must include disclosures pertaining to the use and oversight of the AI, algorithm or other software tool.
- Periodically review the AI, algorithm or other software tool for accuracy and reliability. Ensure fair and equitable use and that it is open to inspection per applicable law.
- Ensure that the tool shall not deny, delay or modify health care services based, in whole or in part, on medical necessity. Only a licensed physician or a licensed health care professional shall make a determination of medical necessity.
- Ensure that the AI, algorithm or other software tool bases its determination on the following information, as applicable:
- An enrollee’s medical or other clinical history.
- Individual clinical circumstances as presented by the requesting physician or other requesting provider.
- Other relevant clinical information contained in the enrollee’s medical or other clinical record.
- Ensure that the AI, algorithm or other software tool has these features:
- Does not base its determination solely on a group dataset.
- Has criteria and guidelines that comply with the bill and applicable law.
- Does not supplant physician or other health care provider decision making.
- Does not discriminate, directly or indirectly, against enrollees in violation of state or federal law.
View the bill online
Access the full bill online at Senate Bill No. 1120.
Additional information
Relevant sections of the provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library on
the provider portal.
Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact Community Health Plan of Imperial Valley at 833-236-4141.
This information applies to Delegated Participating Physician Groups (PPGs).
This information applies to Medi-Cal in Imperial county.