The bill amends Washington state laws to enhance the prior authorization processes for health care services and prescription drugs, ensuring alignment with federal guidelines. Effective January 1, 2024, health carriers and health plans are required to make prior authorization determinations within specific time frames: three calendar days for standard electronic requests and one calendar day for expedited requests. The legislation mandates the establishment of a prior authorization application programming interface (API) that complies with federal standards, treating any prior authorization denials as adverse benefit determinations subject to grievance and appeal processes. Additionally, the bill emphasizes the importance of clear communication regarding prior authorization requirements and mandates that clinical review criteria be evidence-based and inclusive of diverse populations.

Furthermore, the bill sets a timeline for the implementation of the API, requiring health plans and managed care organizations to establish interoperable electronic processes by January 1, 2025, and to support the exchange of prior authorization requests for prescription drugs by January 1, 2027. It outlines specific notification time frames for managed care organizations to inform providers of decisions based on the nature of the request, whether standard or expedited. The legislation also includes provisions to ensure compliance with federal standards, regardless of any potential delays or changes in federal rules, and mandates regular updates to clinical review criteria. Overall, the bill aims to streamline the prior authorization process, enhance transparency, and improve the overall efficiency of health care delivery.

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