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 new standards for health insurance carriers, mandating timely decisions on prior authorization requests with specific time frames for electronic and non-electronic submissions. Carriers are required to clearly communicate their prior authorization requirements, which must be based on peer-reviewed clinical criteria that consider diverse populations. Additionally, when a prior authorization is denied, carriers must include the credentials and specialties of the provider who made the determination in their notifications. The bill also introduces definitions for "generative artificial intelligence" and "machine learning," emphasizing their roles in health care decision-making.

Moreover, the legislation prohibits the use of artificial intelligence as the sole basis for denying care and requires that any AI tools used comply with specific standards to prevent discrimination against enrollees. It mandates the development of an automated application programming interface to streamline the prior authorization process, with a timeline for implementation. Starting January 1, 2024, managed care organizations must adhere to specific time frames for making prior authorization determinations, including three calendar days for standard requests and one calendar day for expedited requests. The bill also prohibits health carriers from retrospectively denying coverage for emergency and nonemergency care that had prior authorization, unless certain conditions are met, and requires annual reporting on prior authorization requests to enhance transparency.

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