On May 13, 2026, Iowa Governor Kim Reynolds signed House File 2635 — the Patients First Act — into law at Monroe County Hospital and Clinics. The law prohibits health insurers in Iowa from using artificial intelligence as the sole basis for denying a prior authorization request. A human clinical reviewer must be in the decision chain. The law takes effect July 1, 2026.

For nurses, this is directly relevant. Prior authorization battles are part of daily clinical workflow — you are frequently the one initiating the request, documenting the clinical justification, and chasing down the denial to figure out how to appeal it. When that denial comes from an algorithm with no clinical context, it creates a specific kind of frustration: there is no one to argue with, no clinical rationale to address, and no clear path to escalation.

What the Law Actually Does

HF 2635 has four core provisions:

  • AI restriction: Insurers cannot use AI to automatically deny or downgrade a prior authorization request. AI can be used in the review process, but only a qualified clinical peer — a physician, NP, or other licensed clinician — can make the final denial or downgrade decision.
  • Clinical peer standard: The law requires that denials and downgrades be reviewed by individuals with appropriate clinical expertise in the relevant specialty, not generic medical directors reviewing outside their training.
  • Cancer screening and emergency exemptions: The law exempts screenings recommended under National Comprehensive Cancer Network (NCCN) guidelines and emergency medical conditions from prior authorization requirements entirely, across private insurance plans, Medicaid-managed care, and the Hawki children's insurance program.
  • Provider protections: The law also prohibits insurers from penalizing physicians for out-of-network referrals and bars unreasonable contract terms in provider-insurer agreements.

Why This Matters at the Bedside

The AI prior authorization problem has been building for years. UnitedHealth Group's subsidiary NaviHealth was at the center of a 2023 lawsuit (now settled) alleging its AI tool, nH Predict, was used to systematically deny post-acute care for Medicare Advantage patients — with a reported 90% denial rate for patients who met clinical criteria for continued care.

More recently, a 2023 Senate Permanent Subcommittee on Investigations report found that Medicare Advantage insurers denied medically necessary care using internal coverage criteria that were more restrictive than Medicare's own guidelines. The AHIP trade group has disputed this framing, but the data pattern is consistent enough across multiple independent investigations that Congress and multiple state legislatures have moved to act.

Iowa's approach is notable because it targets the AI component specifically — not just the outcome of the denial, but the mechanism producing it. The practical effect: every denial in Iowa will require a human fingerprint.

What Does Not Change

Prior authorization still exists. HF 2635 does not eliminate the process, reduce response time requirements, or automatically cover anything that was previously non-covered. The law narrows the tool insurers can use to deny, not the authority to deny. Iowa nurses will still fight prior auth battles on July 1 — they will just be fighting them with a human on the other side of the phone rather than an output from an AI model.

The practical gains are real but limited: a human reviewer is arguable. You can present clinical evidence, cite guidelines, and escalate. An AI output is not. That difference is not nothing, especially for nurses working in SNF or home health settings where post-acute care denials are particularly common and the clinical stakes of getting them wrong are high.

Other States Watching Iowa

Iowa is not alone in this movement. Washington state passed HB 2548 in March 2026, adding restrictions on corporate healthcare ownership transparency. Multiple states have pending legislation addressing AI in prior authorization specifically. At the federal level, the CMS has issued guidance discouraging restrictive internal criteria in Medicare Advantage, and Congress has held multiple hearings on the issue in the 119th session.

If you practice in Iowa, document the effective date (July 1, 2026) and know your appeal rights under the new law. If you're outside Iowa, watch your state's legislative session — this type of bill is moving across the country and it will reach your state's prior authorization workflow sooner than most nurses expect.