Jennifer Hanscom, CEO
Prior authorization is once again making headlines, this time as the Association of Health Insurance Plans announced on Monday “a series of commitments to streamline, simplify and reduce prior authorization.” In its release, AHIP shared that participating health plans commit to standardize and reduce the scope of claims subject to prior authorization.
The several measures will apply to employer-sponsored plans, Medicaid and Medicare, and plans offered by the state’s exchange program.
While Secretary of Health Robert F. Kennedy, Jr., and Centers for Medicare and Medicaid Services Administrator Dr. Mehmet Oz praised the move, many others are taking a wait-and-see approach.
Back in 2017, the WSMA joined the American Medical Association and 16 state and specialty medical societies, national associations, and patient representatives in developing best practices for prior authorization and other utilization management requirements. The release of the 21 prior authorization reform principles initiated meaningful discussions with the health insurance industry about reducing prior authorization burdens resulting in the Consensus Statement on Improving the Prior Authorization Process in 2018, created by the AMA, American Hospital Association, AHIP, American Pharmacists Association, BlueCross BlueShield Association, and Medical Group Management Association. Insurance carriers have since been criticized for not following through with this pledge.
Putting this statement into action, the WSMA has worked to pass policies that have put Washington state at the forefront of states regulating prior authorization processes. Most recently, that includes legislation establishing some of the shortest turnaround times in the nation.
Effective as of Jan. 1, 2024, time frames for both electronic and nonelectronic requests and standard and expedited requests have been shortened to ensure timely patient access to care. Washington state’s prior authorization reforms only apply to commercial plans regulated by our Office of Insurance Commissioner. ERISA plans are exempt.
- Standard electronic prior authorization requests
For a standard electronic prior authorization request, an insurer must make a decision within three calendar days. If additional information is needed to make a determination, the health carrier must request it within one calendar day of the submission of the request. - Expedited electronic prior authorization requests
For an expedited electronic prior authorization request, the insurer must make a decision within one calendar days. If additional information is needed to make a determination, the health carrier must request it within one calendar day of the submission of the request. - Standard nonelectronic prior authorization requests
For a standard nonelectronic prior authorization request, an insurer must make a decision within five calendar days. If additional information is needed to make a determination, the health carrier must request it within five calendar days of the submission of the request. - Expedited nonelectronic prior authorization requests
For an expedited nonelectronic prior authorization request, an insurer must make a decision within two calendar days. If additional information is needed to make a determination, the health carrier must request it within one calendar day of the submission of the request.
The Office of the Insurance Commissioner clarifies that under current law, insurance carriers and third-party administrators are not permitted to require prior authorization for emergency services.
Additionally, no prior authorization is needed for “extenuating circumstances.” Extenuating circumstances are unforeseen situations where the time frames for both standard and expedited prior authorization are insufficient for a physician to receive approval prior to the delivery of a service. You can read more about what classifies as an extenuating circumstance in WSMA’s Prior Authorization Navigator.
By 2027, carriers in Washington state must build and maintain a prior authorization application programming interface or interoperable electronic process that automates for in-network providers the prior authorization process via electronic health records or practice management system.
The new application programming interface requirement will facilitate the process for determining the necessity of a prior authorization, provide information on documentation requirements, and assist with communications between a carrier and the provider or facility, such as requests and determinations. Additional details on new electronic standards are forthcoming. Many of these advancements were made possible by annual data collected by the OIC per WSMA-supported Senate Bill 6404 in 2020, which has illustrated reviews may be administrative formalities rather than true clinical reviews, supporting to the need for these prior authorization reforms.
While prior authorization will continue to make national headlines, the WSMA will continue to advocate locally for change. As covered in our 2025 Legislative Report (a WSMA member benefit that’s currently being mailed to members), the WSMA continues to work on improving transparency and accountability in prior authorization determinations. We will continue to advocate against AI as the sole means of denying a prior authorization and continue to advocate for review by a licensed physician or health professional working within their scope of practice.
Additionally, we heard from the physician community that there are cases where a prior authorization is approved and then later denied, causing physician-led teams to chase payments from carriers. While this is already illegal under state law, we will continue our work to clarify in statute that retrospective denials shall not be considered adverse benefit determinations and will not be required to follow the standard appeal process to avoid another time-consuming hurdle for physicians and their teams.
Your voice matters to the work we do on your behalf. I urge you to continue to be in touch with us with your concerns and stories.
And as always, thank you for all you do.