The bill seeks to improve transparency and accountability in the prior authorization process for health care services and prescription drugs in Washington State. It assigns responsibility for coverage decisions to health insurance carriers and managed care organizations while ensuring that licensed physicians and health professionals determine medical necessity. The legislation introduces specific timelines for prior authorization determinations, requiring decisions within three calendar days for standard requests and one calendar day for expedited requests when submitted electronically. It also mandates that carriers provide clear prior authorization criteria and allows for peer-to-peer review discussions for adverse benefit determinations. Additionally, the bill emphasizes the use of technology, requiring managed care organizations to develop application programming interfaces (APIs) to streamline requests by set deadlines.

Moreover, the bill amends existing laws to include new definitions and requirements for prior authorization processes, such as clarifying that retrospective denials for emergency and nonemergency care with prior authorization will not be deemed adverse benefit determinations. It mandates health carriers to report aggregated and deidentified data on their prior authorization practices annually, starting January 1, 2026, covering various metrics related to requests, approvals, and denials. The legislation also stipulates that if an enrollee or provider can prove that an authorization was valid according to the plan's policies, the carrier must approve and pay for the authorization retroactively, with interest. Overall, the bill aims to streamline the prior authorization process while ensuring fairness and accountability in health care decision-making.

Statutes affected:
Original Bill: 48.43.830, 74.09.840, 41.05.845, 48.43.525, 48.43.0161