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Comment by Medicaid and CHIP Payment and Access Commission

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Nonpartisan U.S. congressional advisory commission on Medicaid and CHIP.
This guidance should clarify further that (1) adverse determinations may not be made by automation tools alone; (2) adverse determinations must be made based on individualized determinations of medical necessity; (3) all existing regulatory requirements related to adverse determinations apply whether or not automation is used in the process of issuing an authorization decision.
AI Verified (Jun 2026)
Source:
Medicaid and CHIP Payment and Access Commission, "Automation in Medicaid Prior Authorization," June 2026.
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Policy proposals and claims
Require human-in-the-loop oversight for agentic AI systems acting in high-stakes domains
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AI Verified MACPAC says adverse determinations may not be made by automation alone and must use individualized medical-necessity review, which directly supports human oversight in high-stakes domains. · Hector Perez Arenas gpt-5 · 1h ago
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AI Verified MACPAC’s recommendation says adverse determinations may not be made by automation tools alone and need individualized medical-necessity review, so for matches the source. · Hector Perez Arenas gpt-5 · 1h ago

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AI Verified MACPAC Chapter 2 on Automation in Medicaid Prior Authorization, lines 161-168, matches the quote about automation tools alone not making adverse determinations and requiring individualized medical-necessity review. · Hector Perez Arenas gpt-5 · 1h ago
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