Amends GS 58-50-61 (concerning utilization reviews), as follows. Defines an urgent health care service to mean a service with respect to which the application of the time periods for making an urgent care determination that, in the opinion of a physician with knowledge of the covered person's medical condition, either: (1) could seriously jeopardize the person's life or health or their ability to regain maximum function or (2) would subject the person to severe pain that can't be adequately managed without the care or treatment that is subject to utilization review. Creates two different timelines for prospective and current utilization reviews based on the urgency of the healthcare service.  Specifies that the current three-business day deadline is for nonurgent healthcare services. For urgent healthcare services, requires the insurer or its utilization review organization (URO) to conduct the review and make the determination or noncertification by not later than 24 hours after receiving the necessary information to conduct the review, unless the reviewer does not has access to the electronic health records of the covered person. Extends the notice obligations pertaining to utilization reviews to URO’s that conduct utilization reviews.   

Sets forth three requirements that apply to an appeals review, including that any appeal not involving a mental health matter be reviewed by a medical doctor meeting the specified criteria, that appeals initiated by a licensed mental health professional be reviewed by either a medical doctor or a licensed mental health professional meeting the prescribed criteria, and the medical doctor or licensed mental health professional to consider all known clinical aspects of the healthcare service under review.  

Requires an insurer to make any current utilization review requirements and restrictions available on its website.  Specifies that any new utilization review requirements or restrictions amendments thereof are not in effect unless and until the insurer’s website has been updated to reflect the new/amended requirements or restrictions. Directs that a claim cannot be denied for failure to obtain a prior authorization if the prior authorization requirement or amended requirement was not in effect on the date of service of the claim.

Sets forth the following requirements that apply to the length of time an approved prior authorization remains valid in certain circumstances:

• If a covered person enrolls in a new health benefit plan offered by the same insurer under which the prior authorization was approved, then the previously approved prior authorization remains valid for the initial days of coverage under the new heath benefit plan. Clarifies that this does not require coverage of a service if it is not a covered service under the new health benefit plan.
• If a healthcare service, other than for in-patient care, requires prior authorization and is for the treatment of a covered person's chronic condition, then the prior authorization shall remain valid for no less than six months from the date the healthcare provider receives notification of the prior authorization approval.

Requires, by January 1, 2028, insurers offering a health benefit plan or a utilization review agent acting on behalf of an insurer offering a health benefit plan, to implement and maintain a prior authorization application programming interface meeting the requirements under 45 C.F.R. § 156.223(b) as it existed on January 1, 2025, which is to be in effect on January 1, 2028.

Extends liability for violations of GS 58-50-61 to agents of the insurer. Prevents an insurer from using an artificial intelligence-based algorithm as the sole basis for a utilization review determination to, in whole or in part, deny, delay, or modify any healthcare services for an insured. Requires insurers to verify that all third-party contacts for conducting utilization reviews are not in violation of the act. Emphasizes that only individuals meeting the licensing and qualification requirements for participating in the utilization review process can make a determination regarding the medical necessity or appropriateness of any healthcare service.

Applies to insurance contracts, including contracts with URO’s, issued, renewed, or amended on or after October 1, 2026.

Directs the State Treasurer and the Executive Administrator of the State Health Plan to review all practices of the State Health Plan and all contracts with, and practices of, any third party conducting any utilization review on behalf of the State Health Plan to ensure compliance with GS 58-50-61, as amended by the act.