Prior Authorization

In January 2018, new state rules went into effect which attempt to ease the administrative burdens faced by physicians and practice staff making a good-faith effort to meet the numerous requirements of prior authorization programs used by Washington insurers.

The adoption of the rules marks the culmination of years of negotiation between the WSMA, the Washington State Hospital Association and the Office of the Insurance Commissioner, and represents a major victory in the WSMA's Healthy Doctors, Healthier Patients initiative.

The new regulations focus on streamlining and standardizing the programs for medical services used by health plans regulated by the OIC, clarifying definitions, setting timelines for standard and expedited requests, establishing clear communication requirements and much more. Similar OIC rules for prescription drug prior authorization programs passed in 2015.

The WSMA Prior Authorization Navigator

To enforce these new requirements, the OIC is relying upon physicians and practices to report to the agency when insurers are out of compliance with the new rules. Physicians and practice staff should familiarize themselves with the WSMA Prior Authorization Navigator, our new mobile-friendly online resource featuring guidance on the new rules and a complaint form designed to easily allow physicians and practices to send a message to the OIC when they encounter a problem.

Visit the WSMA Prior Authorization Navigator for:

  • Key definitions clarifying and standardizing terminology used across insurers and their third-party administrators.
  • New time frames for standard and expedited prior authorization requests, predetermination requests and more.
  • New communication requirements for approvals and denials.
  • Information on medical record requests and documentations.
  • Timeline for insurers to develop and offer an online prior authorization process to include patient-specific information for benefit determination.
  • Information on OIC's 2015 rules on prior authorization of prescription drugs.
  • Easy-to-use complaint form for physicians and practices to use when insurers or TPAs are not in compliance with the rules.

The Navigator is designed to be your partner and protector during the prior authorization process. Keep the Navigator close at hand to quickly refer to the new requirements—and use it to send a message to the OIC each time you encounter a problem.

Visit and bookmark the WSMA Prior Authorization Navigator.