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 time frames for electronic and non-electronic submissions. Carriers must notify providers of standard requests within three calendar days and expedited requests within one calendar day for electronic submissions. The bill emphasizes that licensed physicians and health professionals retain responsibility for medical necessity determinations, even when artificial intelligence (AI) tools are used. Additionally, it requires 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.

Furthermore, the bill introduces definitions related to AI, including "generative artificial intelligence" and "machine learning," and stipulates that prior authorization requests cannot be solely denied or modified based on AI tools without human oversight. Managed care organizations (MCOs) must comply with specific time frames for prior authorization requests and provide clear, accessible requirements. The bill also mandates that any adjustments to prior authorization policies be communicated to in-network providers at least 45 days in advance and that these policies be based on evidence-based clinical review criteria. Health plans are required to report aggregated and deidentified data on prior authorization practices annually, ensuring transparency in the process. Overall, the bill seeks to streamline the prior authorization process while safeguarding patient care and ensuring equitable treatment across diverse 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