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 determinations and notifications for prior authorization requests, with specific timelines of three calendar days for standard electronic requests and one calendar day for expedited requests. The legislation emphasizes that licensed physicians and health professionals retain responsibility for determining medical necessity, even when artificial intelligence (AI) tools are used in decision-making. Key provisions include the requirement for carriers to disclose the credentials of the provider overseeing prior authorization determinations in denial notifications and to maintain an interoperable electronic process for these requests.

Additionally, the bill introduces definitions related to AI, such as "generative artificial intelligence" and "machine learning," and outlines specific criteria for the use of AI in the prior authorization process. It mandates that managed care organizations (MCOs) adhere to defined timelines for prior authorization determinations starting January 1, 2024, and requires them to provide clear and accessible prior authorization requirements. The bill also prohibits retrospective denial of coverage for services that had prior authorization, except under specific circumstances, and mandates annual reporting of aggregated data on prior authorization practices, including the use of AI, to ensure transparency. Overall, the legislation seeks to streamline the prior authorization process while ensuring fairness and equity, particularly for underserved populations.

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