The bill seeks to enhance the prior authorization process in healthcare by mandating the implementation of application programming interfaces (APIs) that align with federal guidelines for health plans issued or renewed on or after January 1, 2024. It establishes strict timelines for carriers to make prior authorization determinations, requiring decisions on electronic standard requests within three calendar days and expedited requests within one calendar day. The bill also stipulates that prior authorization denials are classified as adverse benefit determinations, which are subject to grievance and appeal processes. Furthermore, it requires that prior authorization criteria be communicated clearly and based on peer-reviewed clinical evidence, with annual updates to reflect new findings, particularly for underserved populations.

Additionally, the bill mandates that health plans and managed care organizations develop interoperable electronic processes or APIs to facilitate the exchange of prior authorization requests and determinations for healthcare services and prescription drugs. Starting January 1, 2025, health plans must implement an API that complies with federal regulations, and by January 1, 2027, they must support the exchange of prior authorization requests for prescription drugs, including information on covered alternatives. The bill emphasizes the importance of transparency and accessibility in the prior authorization process, ensuring that requirements are based on clinical criteria and accommodating diverse populations. If federal rules regarding API use are not finalized by September 13, 2023, enforcement of these requirements may be postponed until the final rules are established.

Statutes affected:
Original Bill: 48.43.830, 41.05.845, 74.09.840