Prior Authorization

Reducing the negative impact of insurance carrier prior authorization processes on Washington’s physicians, physician assistants, and patients continues to be a top priority of the WSMA.

In 2023, the WSMA championed House Bill 1357, sponsored by Rep. Tara Simmons (D-Bremerton), to facilitate the transition to electronic prior authorization processes and shorten processing timelines across state-regulated insurance plans for both health care services and prescription drugs.

Beginning in 2024, Washington physicians can expect tighter turnaround times for prior authorization approvals and notifications, as well as increased transparency around insurance carrier prior authorization programs. These changes are intended to reduce administrative burden for health professionals, generate significant cost savings, and improve patient health outcomes.

New Prior Authorization Time Frames in Effect in Washington State

New insurance carrier requirements for prior authorization time frames went into effect Jan. 1, 2024 as a result of WSMA-championed House Bill 1357 from the 2023 legislative session. With new requirements in effect, the WSMA has updated its Prior Authorization Navigator to ensure our members reap the full benefits of our advocacy work and that they understand the new reforms contained in HB 1357 and recent related rulemaking.

Shorter turnaround times

Effective Jan. 1, time frames for both electronic and nonelectronic requests and standard and expedited requests have been shortened to ensure timely patient access to care. Visit the Prior Authorization Navigator for a rundown of the shortened turnaround times for prior authorizations for both health care services (look under Administrative Requirements) and prescription drugs.

To come in 2026-27: EHR integration

New interoperability standards, which take effect in 2026 for health care services and 2027 for prescription drugs, will require insurers and third-party administrators to create application programming interfaces or interoperable electronic processes that will connect to a physician’s electronic health record system to enable a streamlined process for submitting requests and reduce administrative burden. Thanks to WSMA’s leadership, Washington is the first state in the nation to require carriers to receive prior authorization requests via physician practice EHR.

About the Prior Authorization Navigator

The WSMA originally introduced its Prior Authorization Navigator in 2018 as a mobile-friendly “one-stop shop” for guidance on existing and new state prior authorization requirements. Newly updated and reformatted, the WSMA urges all health care professionals who find themselves engaged in prior authorization processes to use the Prior Authorization Navigator at priorauth.wsma.org to review the new and existing state prior authorization requirements.

What health plans are covered

The 2019 rulemaking and HB 1357 apply to plans regulated by the Office of the Insurance Commissioner:

• Individual (both on and off the Washington Health Benefit Exchange).
• Small group.
• Large group (other than self-insured).

Filing a complaint

Insurers are obligated to ensure their third-party administrators comply with these new requirements. The Office of the Insurance Commissioner enforces its requirements using a complaint-driven process. If an insurer or third-party administrator is out of compliance with prior authorization requirements as described in the Navigator, file a complaint using the Navigator’s complaint form.

Apple Health (Medicaid) Prior Authorization Resources

The Health Care Authority allows physicians and health professionals caring for patients enrolled in Apple Health or the Public Employees Benefits Board to submit prior authorizations for medical requests and all backup documentation online. Visit the HCA's dedicated prior authorization webpage for more information.