The bill aims to improve transparency and accountability in the prior authorization process for health care services and prescription drugs in Washington State. It establishes strict time frames for health carriers to respond to prior authorization requests, requiring responses within three calendar days for standard electronic requests and one calendar day for expedited requests. The legislation mandates that licensed physicians or health professionals oversee these determinations, ensuring that artificial intelligence (AI) cannot solely dictate decisions regarding medical necessity. Additionally, the bill includes provisions for managed care organizations, ensuring equitable patient protections across various income levels.

Key provisions of the bill include the requirement for carriers to clearly communicate prior authorization requirements, the establishment of an interoperable electronic process for requests, and the obligation to provide detailed information about the provider overseeing any denial. The bill also outlines the responsibilities of carriers using AI, ensuring that such technology is not used discriminatorily and is subject to human review. Furthermore, it amends existing laws to prevent retrospective denials of coverage for services that had prior authorization, unless there is a material misrepresentation. The legislation aims to create a more transparent, fair, and efficient prior authorization process while safeguarding patient rights and ensuring equitable access to 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
Second substitute: 48.43.830, 41.05.845, 48.43.525, 48.43.0161
Engrossed second substitute: 48.43.830, 41.05.845, 48.43.525, 48.43.0161
Bill as passed Legislature: 48.43.830, 41.05.845, 48.43.525, 48.43.535, 48.43.0161
Session law: 48.43.830, 41.05.845, 48.43.525, 48.43.535, 48.43.0161