The bill seeks to enhance the prior authorization processes in healthcare by aligning them with federal guidelines, particularly for health plans issued or renewed on or after January 1, 2024. It establishes strict timelines for prior authorization determinations, mandating that carriers notify providers of decisions within three calendar days for standard electronic requests and one calendar day for expedited requests. For nonelectronic requests, the timelines are five days for standard and two days for expedited. Additionally, the bill requires carriers to provide clear prior authorization requirements based on evidence-based clinical review criteria, ensuring these criteria are regularly updated, especially for underserved populations.

Furthermore, the bill mandates that health plans and managed care organizations implement interoperable electronic processes or application programming interfaces (APIs) to facilitate the exchange of prior authorization requests and determinations for healthcare services and prescription drugs. The implementation deadlines are set for January 1, 2025, for healthcare services and January 1, 2027, for prescription drugs. The bill also stipulates that any prior authorization denial or authorization of a less intensive service must be classified as an adverse benefit determination, subject to the grievance and appeal process. Enforcement of these requirements is contingent upon the finalization of federal rules, with a provision allowing enforcement to begin on January 1, 2027, regardless of any delays in federal regulations.

Statutes affected:
Original Bill: 48.43.830, 41.05.845, 74.09.840
Substitute Bill: 48.43.830, 41.05.845, 74.09.840
Bill as Passed Legislature: 48.43.830, 41.05.845, 74.09.840
Session Law: 48.43.830, 41.05.845, 74.09.840