Prior Authorization
Reducing the negative impact of insurance carrier prior authorization
processes on Washingtonians’ ability to access needed care as well as on the practice of medicine for physicians and health care practitioners
continues to be a top priority of the WSMA.
Improving Transparency and Accountability in the Prior Authorization Processes
During the 2025 state legislative session, the WSMA is working in coalition with the Washington State Hospital Association and Proliance Surgeons on legislation to improve transparency and accountability in the prior authorization process: Senate Bill 5395, sponsored by Sen. Tina Orwall (D-Des Moines), and House Bill 1566, sponsored by Rep. Alicia Rule (D-Blaine).
This year’s legislation is part of an ongoing effort to reduce the negative impact of insurance carrier prior authorization processes on patients’ access to care and on the practice of medicine for physicians and health care practitioners. In 2020 and 2023, the WSMA worked to pass legislation requiring carriers to provide data on their prior authorization practices, shorten prior authorization determination timelines, implement application programming interfaces for prior authorization processes, and more (details on that legislation, below).
SB 5395 and HB 1566 would build upon past efforts by prohibiting artificial intelligence from being the sole means to deny a prior authorization, ensuring that any denial of a prior authorization request can only be made upon review by a licensed physician or health professional working within their scope of practice.
Additionally, the bill would clarify current state law prohibiting retrospective denials, making it clear that retrospective denials of coverage due to a change in the carrier’s determination of medical necessity are prohibited. The bill also clarifies that retrospective denials shall not be considered adverse benefit determinations subject to a carrier’s standard appeals process. This would increase awareness and accountability of current law and ensure prior authorization determinations and payment are not clawed back after the service has been provided.
The WSMA has been engaged in extensive negotiation with our partners, state agencies, and insurance carriers on both bills and will continue to prioritize this important issue before the Legislature.
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.