The bill seeks to modernize the prior authorization process for health care services and prescription drugs in Washington State, establishing specific time frames for health carriers and managed care organizations to make determinations. Starting January 1, 2024, electronic standard requests must be decided within three calendar days, while expedited requests require a decision within one calendar day. For nonelectronic requests, standard determinations are set at five calendar days, and expedited requests at two calendar days. The bill also mandates the development and maintenance of an application programming interface (API) to automate the prior authorization process, with full implementation deadlines of January 1, 2025, for health care services and January 1, 2027, for prescription drugs. If federal standards for APIs are not finalized by September 13, 2023, enforcement of certain requirements may be delayed until January 1, 2026.

Additionally, the bill introduces new reporting requirements for insurance carriers, mandating them to report data on prior authorization requests, including approval rates and average response times. It emphasizes the use of evidence-based clinical review criteria that consider the needs of diverse populations and outlines a process for handling prior authorization denials. Managed care organizations that cannot meet the specified deadlines must submit a justification to the authority, which may grant a one-year delay in enforcement if a good faith effort to comply is demonstrated. The act is set to take effect on January 1, 2024, unless specific funding is not provided by June 30, 2023, in which case it will be null and void.

Statutes affected:
Original Bill: 48.43.0161, 48.43.545
Substitute Bill: 48.43.0161
Second Substitute: 48.43.420, 48.43.0161, 48.43.400
Engrossed Second Substitute: 48.43.0161
Bill as Passed Legislature: 48.43.0161
Session Law: 48.43.0161