The bill seeks to improve transparency and accountability in the prior authorization process for health care services and prescription drugs in Washington State. It establishes new standards for health insurance carriers, mandating timely responses to prior authorization requests—three calendar days for standard requests and one calendar day for expedited requests. The bill emphasizes that licensed physicians and health professionals are responsible for coverage determinations, and if artificial intelligence (AI) is used, it cannot be the sole basis for denying care. Additionally, carriers must disclose the credentials of the provider overseeing prior authorization determinations in denial notifications and maintain an interoperable electronic process for these requests.

Key provisions include the requirement for managed care organizations (MCOs) to report quarterly on prior authorization requests and their outcomes, including the role of AI. The bill introduces definitions related to AI and prior authorization requests, ensuring that AI cannot solely determine medical necessity without human oversight. It also allows for a one-year delay in enforcement of certain requirements if a health plan demonstrates a good faith effort to comply. Furthermore, health carriers are prohibited from retrospectively denying coverage for emergency and nonemergency care that had prior authorization, except under specific circumstances. Overall, the bill aims to streamline the prior authorization process while ensuring that patients have timely access to necessary health care services.

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