The bill amends Washington state laws to enhance the prior authorization processes for health care services and prescription drugs, aligning them with federal guidelines. Effective January 1, 2024, health carriers and health plans 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, the bill mandates the establishment of a prior authorization application programming interface (API) that complies with federal standards, ensuring that any prior authorization denials are treated as adverse benefit determinations, which are subject to grievance and appeal processes. The implementation of the API for prescription drugs is scheduled to begin on January 1, 2027.

Furthermore, the bill emphasizes the importance of clear communication regarding prior authorization requirements, mandating that they be presented in understandable language and made available electronically to providers. It also requires that clinical review criteria be evidence-based and inclusive of diverse populations. Health plans and managed care organizations must implement interoperable electronic processes or APIs by January 1, 2025, to facilitate the exchange of prior authorization requests and determinations. The bill outlines specific time frames for notifying providers of decisions and ensures compliance with federal regulations, establishing a timeline for enforcement of these requirements.

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