The bill aims to improve transparency and accountability in the prior authorization process for healthcare services and prescription drugs in Washington State. It establishes specific time frames for health insurance carriers to make prior authorization determinations, requiring decisions on standard electronic requests within three calendar days and expedited requests within one calendar day. The bill emphasizes that licensed physicians and health professionals are responsible for determining medical necessity and prohibits the sole use of artificial intelligence (AI) in denying or modifying healthcare services without human oversight. Additionally, it mandates that carriers provide clear prior authorization requirements, maintain an interoperable electronic process, and post any changes to their policies on their websites.

Key provisions include the requirement for carriers to request additional information within specified time frames if needed for determinations, and to provide detailed information about the credentials of the provider who made a denial decision. The bill also prohibits retrospective denials of coverage for services that had prior authorization, except in cases of material misrepresentation. It sets a timeline for health carriers to report aggregated data on prior authorization practices and establishes a framework for evaluating the effectiveness of the new regulations, with certain sections set to expire on January 1, 2027, allowing for stakeholder input and potential revisions.

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
Second substitute: 48.43.830, 41.05.845, 48.43.525, 48.43.0161