The bill seeks to enhance the prior authorization process in healthcare by aligning it with federal guidelines and establishing specific timelines for health plans issued or renewed on or after January 1, 2024. It mandates that carriers notify providers of prior authorization decisions within three calendar days for standard electronic requests and one calendar day for expedited requests, with longer time frames for nonelectronic requests. Additionally, the bill requires carriers to provide clear prior authorization requirements based on evidence-based clinical review criteria, which must be regularly updated, particularly for underserved populations.

Furthermore, the bill mandates the establishment and maintenance of interoperable application programming interfaces (APIs) by health plans and managed care organizations to facilitate the exchange of prior authorization requests and determinations for healthcare services and prescription drugs. The implementation deadlines for these APIs are set for January 1, 2025, for healthcare services and January 1, 2027, for prescription drugs. The bill also stipulates that any prior authorization denial or authorization of a less intensive service is considered an adverse benefit determination, subject to grievance and appeal processes. Enforcement of these requirements will commence on January 1, 2027, regardless of any federal rule changes.

Statutes affected:
Original Bill: 48.43.830, 41.05.845, 74.09.840
Substitute Bill: 48.43.830, 41.05.845, 74.09.840