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 timelines 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 health professionals oversee these determinations, ensuring that artificial intelligence (AI) cannot solely dictate decisions regarding medical necessity. Additionally, carriers must provide clear and accessible prior authorization requirements based on peer-reviewed clinical criteria that consider the needs of diverse populations, including underserved groups.

Significant provisions include the requirement for carriers to disclose the credentials of providers overseeing any denial of prior authorization and to ensure that AI cannot be the sole basis for denying care without human review. The bill also enhances the independent review process for enrollees disputing coverage decisions, allowing them to bypass certain grievance procedures when seeking external review. Carriers are required to report aggregated data on prior authorization practices by October 1, 2026, including metrics on AI-aided denials and response times. Overall, the legislation seeks to protect patients from potential biases in AI decision-making while ensuring a fair and efficient process for health care authorization and appeals.

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