The bill amends existing laws to enhance the prior authorization processes for health care services and prescription drugs, ensuring alignment with federal guidelines. Effective January 1, 2024, health carriers are required to make prior authorization determinations within specific time frames: three calendar days for standard electronic requests and one calendar day for expedited requests. Additionally, health plans must establish and maintain a prior authorization application programming interface (API) that meets federal standards. Denials of prior authorization will be classified as adverse benefit determinations, which will be subject to grievance and appeal processes.

Furthermore, the bill mandates that health plans for public employees and their dependents adhere to similar prior authorization standards, including the same time frames for both electronic and non-electronic requests. The API must facilitate the exchange of prior authorization requests and determinations, utilizing evidence-based clinical review criteria that are regularly updated. The enforcement of these requirements is set to begin on January 1, 2027, regardless of any changes to federal rules regarding APIs. Overall, the bill aims to streamline the prior authorization process, improve transparency, and ensure compliance with federal regulations while addressing the needs of providers and enrollees.

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