Prior auth. APIs/health

AN ACT Relating to aligning the implementation of application 1
programming interfaces for prior authorization with federal 2
guidelines; and amending RCW 48.43.830, 41.05.845, and 74.09.840.3
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:4
Sec. 1. RCW 48.43.830 and 2023 c 382 s 1 are each amended to 5
read as follows: 6
(1) Each carrier offering a health plan issued or renewed on or 7
after January 1, 2024, shall comply with the following standards 8
related to prior authorization for health care services and 9
prescription drugs: 10
(a) The carrier shall meet the following time frames for prior 11
authorization determinations and notifications to a participating 12
provider or facility that submits the prior authorization request 13
through an electronic prior authorization process, as designated by 14
each carrier: 15
(i) For electronic standard prior authorization requests, the 16
carrier shall make a decision and notify the provider or facility of 17
the results of the decision within three calendar days, excluding 18
holidays, of submission of an electronic prior authorization request 19
by the provider or facility that contains the necessary information 20
to make a determination. If insufficient information has been 21
H-0833.1
HOUSE BILL 1706
State of Washington 69th Legislature 2025 Regular Session
By Representative Simmons
Read first time 01/29/25. Referred to Committee on Health Care &
Wellness.
p. 1 HB 1706
provided to the carrier to make a decision, the carrier shall request 1
any additional information from the provider or facility within one 2
calendar day of submission of the electronic prior authorization 3
request. 4
(ii) For electronic expedited prior authorization requests, the 5
carrier shall make a decision and notify the provider or facility of 6
the results of the decision within one calendar day of submission of 7
an electronic prior authorization request by the provider or facility 8
that contains the necessary information to make a determination. If 9
insufficient information has been provided to the carrier to make a 10
decision, the carrier shall request any additional information from 11
the provider or facility within one calendar day of submission of the 12
electronic prior authorization request. 13
(b) The carrier shall meet the following time frames for prior 14
authorization determinations and notifications to a participating 15
provider or facility that submits the prior authorization request 16
through a process other than an electronic prior authorization 17
process: 18
(i) For nonelectronic standard prior authorization requests, the 19
carrier shall make a decision and notify the provider or facility of 20
the results of the decision within five calendar days of submission 21
of a nonelectronic prior authorization request by the provider or 22
facility that contains the necessary information to make a 23
determination. If insufficient information has been provided to the 24
carrier to make a decision, the carrier shall request any additional 25
information from the provider or facility within five calendar days 26
of submission of the nonelectronic prior authorization request.27
(ii) For nonelectronic expedited prior authorization requests, 28
the carrier shall make a decision and notify the provider or facility 29
of the results of the decision within two calendar days of submission 30
of a nonelectronic prior authorization request by the provider or 31
facility that contains the necessary information to make a 32
determination. If insufficient information has been provided to the 33
carrier to make a decision, the carrier shall request any additional 34
information from the provider or facility within one calendar day of 35
submission of the nonelectronic prior authorization request.36
(c) In any instance in which a carrier has determined that a 37
provider or facility has not provided sufficient information for 38
making a determination under (a) and (b) of this subsection, a 39
carrier may establish a specific reasonable time frame for submission 40
p. 2 HB 1706
of the additional information. This time frame must be communicated 1
to the provider and enrollee with a carrier's request for additional 2
information. 3
(d) The carrier's prior authorization requirements must be 4
described in detail and written in easily understandable language. 5
The carrier shall make its most current prior authorization 6
requirements and restrictions, including the written clinical review 7
criteria, available to providers and facilities in an electronic 8
format upon request. The prior authorization requirements must be 9
based on peer-reviewed clinical review criteria. The clinical review 10
criteria must be evidence-based criteria and must accommodate new and 11
emerging information related to the appropriateness of clinical 12
criteria with respect to black and indigenous people, other people of 13
color, gender, and underserved populations. The clinical review 14
criteria must be evaluated and updated, if necessary, at least 15
annually. 16
(2)(a) Each carrier shall ((build and maintain a prior 17
authorization application programming interface that automates the 18
process for in-network providers to determine whether a prior 19
authorization is required for health care services, identify prior 20
authorization information and documentation requirements, and 21
facilitate the exchange of prior authorization requests and 22
determinations from its electronic health records or practice 23
management system. The application programming interface must support 24
the exchange of prior authorization requests and determinations for 25
health care services beginning January 1, 2025, and must:26
(i) Use health level 7 fast health care interoperability 27
resources in accordance with standards and provisions defined in 45 28
C.F.R. Sec. 170.215 and 45 C.F.R. Sec. 156.22(3)(b);29
(ii) Automate the process to determine whether a prior 30
authorization is required for durable medical equipment or a health 31
care service;32
(iii) Allow providers to query the carrier's prior authorization 33
documentation requirements;34
(iv) Support an automated approach using nonproprietary open 35
workflows to compile and exchange the necessary data elements to 36
populate the prior authorization requirements that are compliant with 37
the federal health insurance portability and accountability act of 38
1996 or have an exception from the federal centers for medicare and 39
medicaid services; and40
p. 3 HB 1706
(v) Indicate that)) establish and maintain a prior authorization 1
application programming interface that is consistent with final rules 2
issued by the federal centers for medicare and medicaid services and 3
published in the federal register, and that indicates that a prior 4
authorization denial or authorization of a service less intensive 5
than that included in the original request is an adverse benefit 6
determination and is subject to the carrier's grievance and appeal 7
process under RCW 48.43.535. The implementation of the application 8
programming interface must align with federal effective dates, 9
including enforcement delays and suspensions, issued by the federal 10
centers for medicare and medicaid services.11
(b) Each carrier shall establish and maintain an interoperable 12
electronic process or application programming interface that 13
automates the process for in-network providers to determine whether a 14
prior authorization is required for a covered prescription drug. The 15
interoperable electronic process or application programming interface 16
must support the exchange of prior authorization requests and 17
determinations for prescription drugs, including information on 18
covered alternative prescription drugs, beginning January 1, 2027, 19
and must: 20
(i) Allow providers to identify prior authorization information 21
and documentation requirements; 22
(ii) Facilitate the exchange of prior authorization requests and 23
determinations from its electronic health records or practice 24
management system ((, and may include the necessary data elements to 25
populate the prior authorization requirements that are compliant with 26
the federal health insurance portability and accountability act of 27
1996 or have an exception from the federal centers for medicare and 28
medicaid services)); and 29
(iii) Indicate that a prior authorization denial or authorization 30
of a drug other than the one included in the original prior 31
authorization request is an adverse benefit determination and is 32
subject to the carrier's grievance and appeal process under RCW 33
48.43.535. 34
(c) If federal rules related to standards for using an 35
application programming interface to communicate prior authorization 36
status to providers are not finalized by the federal centers for 37
medicare and medicaid services by September 13, 2023, the 38
requirements of (a) of this subsection may not be enforced until 39
p. 4 HB 1706
((January 1, 2026 )) final rules published by the federal government 1
take effect. 2
(d)(((i) If a carrier determines that it will not be able to 3
satisfy the requirements of (a) of this subsection by January 1, 4
2025, the carrier shall submit a narrative justification to the 5
commissioner on or before September 1, 2024, describing:6
(A) The reasons that the carrier cannot reasonably satisfy the 7
requirements;8
(B) The impact of noncompliance upon providers and enrollees;9
(C) The current or proposed means of providing health information 10
to the providers; and11
(D) A timeline and implementation plan to achieve compliance with 12
the requirements.13
(ii) The commissioner may grant a one-year delay in enforcement 14
of the requirements of (a) of this subsection (2) if the commissioner 15
determines that the carrier has made a good faith effort to comply 16
with the requirements.17
(iii) This subsection (2)(d) shall not apply if the delay in 18
enforcement in (c) of this subsection takes effect because the 19
federal centers for medicare and medicaid services did not finalize 20
the applicable regulations by September 13, 2023.21
(e))) By September 13, 2023, and at least every six months 22
thereafter until September 13, 2026, the commissioner shall provide 23
an update to the health care policy committees of the legislature on 24
the development of rules and implementation guidance from the federal 25
centers for medicare and medicaid services regarding the standards 26
for development of application programming interfaces and 27
interoperable electronic processes related to prior authorization 28
functions. The updates should include recommendations, as 29
appropriate, on whether the status of the federal rule development 30
aligns with the provisions of chapter 382, Laws of 2023. The 31
commissioner also shall report on any actions by the federal centers 32
for medicare and medicaid services to exercise enforcement discretion 33
related to the implementation and maintenance of an application 34
programming interface for prior authorization functions. The 35
commissioner shall consult with the health care authority, carriers, 36
providers, and consumers on the development of these updates and any 37
recommendations. 38
(3) Nothing in this section applies to prior authorization 39
determinations made pursuant to RCW 48.43.761. 40
p. 5 HB 1706
(4) For the purposes of this section: 1
(a) "Expedited prior authorization request" means a request by a 2
provider or facility for approval of a health care service or 3
prescription drug where: 4
(i) The passage of time: 5
(A) Could seriously jeopardize the life or health of the 6
enrollee; 7
(B) Could seriously jeopardize the enrollee's ability to regain 8
maximum function; or 9
(C) In the opinion of a provider or facility with knowledge of 10
the enrollee's medical condition, would subject the enrollee to 11
severe pain that cannot be adequately managed without the health care 12
service or prescription drug that is the subject of the request; or13
(ii) The enrollee is undergoing a current course of treatment 14
using a nonformulary drug. 15
(b) "Standard prior authorization request" means a request by a 16
provider or facility for approval of a health care service or 17
prescription drug where the request is made in advance of the 18
enrollee obtaining a health care service or prescription drug that is 19
not required to be expedited. 20
Sec. 2. RCW 41.05.845 and 2023 c 382 s 2 are each amended to 21
read as follows: 22
(1) A health plan offered to public employees, retirees, and 23
their covered dependents under this chapter issued or renewed on or 24
after January 1, 2024, shall comply with the following standards 25
related to prior authorization for health care services and 26
prescription drugs: 27
(a) The health plan shall meet the following time frames for 28
prior authorization determinations and notifications to a 29
participating provider or facility that submits the prior 30
authorization request through an electronic prior authorization 31
process: 32
(i) For electronic standard prior authorization requests, the 33
health plan shall make a decision and notify the provider or facility 34
of the results of the decision within three calendar days, excluding 35
holidays, of submission of an electronic prior authorization request 36
by the provider or facility that contains the necessary information 37
to make a determination. If insufficient information has been 38
provided to the health plan to make a decision, the health plan shall 39
p. 6 HB 1706
request any additional information from the provider or facility 1
within one calendar day of submission of the electronic prior 2
authorization request. 3
(ii) For electronic expedited prior authorization requests, the 4
health plan shall make a decision and notify the provider or facility 5
of the results of the decision within one calendar day of submission 6
of an electronic prior authorization request by the provider or 7
facility that contains the necessary information to make a 8
determination. If insufficient information has been provided to the 9
health plan to make a decision, the health plan shall request any 10
additional information from the provider or facility within one 11
calendar day of submission of the electronic prior authorization 12
request. 13
(b) The health plan shall meet the following time frames for 14
prior authorization determinations and notifications to a 15
participating provider or facility that submits the prior 16
authorization request through a process other than an electronic 17
prior authorization process described in subsection (2) of this 18
section: 19
(i) For nonelectronic standard prior authorization requests, the 20
health plan shall make a decision and notify the provider or facility 21
of the results of the decision within five calendar days of 22
submission of a nonelectronic prior authorization request by the 23
provider or facility that contains the necessary information to make 24
a determination. If insufficient information has been provided to the 25
health plan to make a decision, the health plan shall request any 26
additional information from the provider or facility within five 27
calendar days of submission of the nonelectronic prior authorization 28
request. 29
(ii) For nonelectronic expedited prior authorization requests, 30
the health plan shall make a decision and notify the provider or 31
facility of the results of the decision within two calendar days of 32
submission of a nonelectronic prior authorization request by the 33
provider or facility that contains the necessary information to make 34
a determination. If insufficient information has been provided to the 35
health plan to make a decision, the health plan shall request any 36
additional information from the provider or facility within one 37
calendar day of submission of the nonelectronic prior authorization 38
request. 39
p. 7 HB 1706
(c) In any instance in which the health plan has determined that 1
a provider or facility has not provided sufficient information for 2
making a determination under (a) and (b) of this subsection, the 3
health plan may establish a specific reasonable time frame for 4
submission of the additional information. This time frame must be 5
communicated to the provider and enrollee with the health plan's 6
request for additional information. 7
(d) The prior authorization requirements of the health plan must 8
be described in detail and written in easily understandable language. 9
The health plan shall make its most current prior authorization 10
requirements and restrictions, including the written clinical review 11
criteria, available to providers and facilities in an electronic 12
format upon request. The prior authorization requirements must be 13
based on peer-reviewed clinical review criteria. The clinical review 14
criteria must be evidence-based criteria and must accommodate new and 15
emerging information related to the appropriateness of clinical 16
criteria with respect to black and indigenous people, other people of 17
color, gender, and underserved populations. The clinical review 18
criteria must be evaluated and updated, if necessary, at least 19
annually. 20
(2)(a) Each health plan offered to public employees, retirees, 21
and their covered dependents under this chapter shall ((build and 22
maintain a prior authorization application programming interface that 23
automates the process for in-network providers to determine whether a 24
prior authorization is required for health care services, identify 25
prior authorization information and documentation requirements, and 26
facilitate the exchange of prior authorization requests and 27
determinations from its electronic health records or practice 28
management system. The application programming interface must support 29
the exchange of prior authorization requests and determinations for 30
health care services beginning January 1, 2025, and must:31
(i) Use health level 7 fast health care interoperability 32
resources in accordance with standards and provisions defined in 45 33
C.F.R. Sec. 170.215 and 45 C.F.R. Sec. 156.22(3)(b);34
(ii) Automate the process to determine whether a prior 35
authorization is required for durable medical equipment or a health 36
care service;37
(iii) Allow providers to query the health plan's prior 38
authorization documentation requirements;39
p. 8 HB 1706
(iv) Support an automated approach using nonproprietary open 1
workflows to compile and exchange the necessary data elements to 2
populate the prior authorization requirements that are compliant with 3
the federal health insurance portability and accountability act of 4
1996 or have an exception from the federal centers for medicare and 5
medicaid services; and6
(v) Indicate that)) establish and maintain a prior authorization 7
application programming interface that is consistent with final rules 8
issued by the federal centers for medicare and medicaid services and 9
published in the federal register, and that indicates that a prior 10
authorization denial or authorization of a service less intensive 11
than that included in the original request is an adverse benefit 12
determination and is subject to the health plan's grievance and 13
appeal process under RCW 48.43.535. The implementation of the 14
application programming interface must align with federal effective 15
dates, including enforcement delays and suspensions, issued by the 16
federal centers for medicare and medicaid services.17
(b) Each health plan offered to public employees, retirees, and 18
their covered dependents under this chapter shall establish and 19
maintain an interoperable electronic process or application 20
programming interface that automates the process for in-network 21
providers to determine whether a prior authorization is required for 22
a covered prescription drug. The interoperable electronic process or 23
application programming interface must support the exchange of prior 24
authorization requests and determinations for prescription drugs, 25
including information on covered alternative prescription drugs, 26
beginning January 1, 2027, and must: 27
(i) Allow providers to identify prior authorization information 28
and documentation requirements; 29
(ii) Facilitate the exchange of prior authorization requests and 30
determinations from its electronic health records or practice 31
management system ((, and may include the necessary data elements to 32
populate the prior authorization requirements that are compliant with 33
the federal health insurance portability and accountability act of 34
1996 or have an exception from the federal centers for medicare and 35
medicaid services)); and 36
(iii) Indicate that a prior authorization denial or authorization 37
of a drug other than the one included in the original prior 38
authorization request is an adverse benefit determination and is 39
p. 9 HB 1706
subject to the health plan's grievance and appeal process under RCW 1
48.43.535. 2
(c) If federal rules related to standards for using an 3
application programming interface to communicate prior authorization 4
status to providers are not finalized by the federal centers for 5
medicare and medicaid services by September 13, 2023, the 6
requirements of (a) of this subsection may not be enforced until 7
((January 1, 2026 )) final rules published by the federal government 8
take effect. 9
(((d)(i) If the health plan determines that it will not be able 10
to satisfy the requirements of (a) of this subsection by January 1, 11
2025, the health plan shall submit a narrative justification to the 12
authority on or before September 1, 2024, describing:13
(A) The reasons that the health plan cannot reasonably satisfy 14
the requirements;15
(B) The impact of noncompliance upon providers and enrollees;16
(C) The current or proposed means of providing health information 17
to the providers; and18
(D) A timeline and implementation plan to achieve compliance with 19
the requirements.20
(ii) The authority may grant a one-year delay in enforcement of 21
the requirements of (a) of this subsection (2) if the authority 22
determines that the health plan has made a good faith effort to 23
comply with the requirements.24
(iii) This subsection (2)(d) shall not apply if the delay in 25
enforcement in (c) of this subsection takes effect because the 26
federal centers for medicare and medicaid services did not finalize 27
the applicable regulations by September 13, 2023.))28
(3) Nothing in this section applies to prior authorization 29
determinations made pursuant to RCW 41.05.526. 30
(4) For the purposes of this section: 31
(a) "Expedited prior authorization request" means a request by a 32
provider or facility for approval of a health care service or 33
prescription drug where: 34
(i) The passage of time: 35
(A) Could seriously jeopardize the life or health of the 36
enrollee; 37
(B) Could seriously jeopardize the enrollee's ability to regain 38
maximum function; or 39
p. 10 HB 1706
(C) In the opinion of a provider or facility with knowledge of 1
the enrollee's medical condition, would subject the enrollee to 2
severe pain that cannot be adequately managed without the health care 3
service or prescription drug that is the subject of the request; or4
(ii) The enrollee is undergoing a current course of treatment 5
using a nonformulary drug. 6
(b) "Standard prior authorization request" means a request by a 7
provider or facility for approval of a health care service or 8
prescription drug where the request is made in advance of the 9
enrollee obtaining a health care service that is not required to be 10
expedited. 11
(5) This section shall not apply to coverage provided under the 12
medicare part C or part D programs set forth in Title XVIII of the 13
social security act of 1965, as amended. 14
Sec. 3. RCW 74.09.840 and 2023 c 382 s 3 are each amended to 15
read as follows: 16
(1) Beginning January 1, 2024, the authority shall require each 17
managed care organization to comply with the following standards 18
related to prior authorization for health care services and 19
prescription drugs: 20
(a) The managed care organization shall meet the following time 21
frames for prior authorization determinations and notifications to a 22
participating provider or facility that submits the prior 23
authorization request through an electronic prior authorization 24
process, as designated by each managed care organization:25
(i) For electronic standard prior authorization requests, the 26
managed care organization shall make a decision and notify the 27
provider or facility of the results of the decision within three 28
calendar days, excluding holidays, of submission of an electronic 29
prior authorization request by the provider or facility that contains 30
the necessary information to make a determination. If insufficient 31
information has been provided to the managed care organization to 32
make a decision, the managed care organization shall request any 33
additional information from the provider or facility within one 34
calendar day of submission of the electronic prior authorization 35
request. 36
(ii) For electronic expedited prior authorization requests, the 37
managed care organization shall make a decision and notify the 38
provider or facility of the results of the decision within one 39
p. 11 HB 1706
calendar day of submission of an electronic prior authorization 1
request by the provider or facility that contains the necessary 2
information to make a determination. If insufficient information has 3
been provided to the managed care organization to make a decision, 4
the managed care organization shall request any additional 5
information from the provider or facility within one calendar day of 6
submission of the electronic prior authorization request.7
(b) The managed care organization shall meet the following time 8
frames for prior authorization determinations and notifications to a 9
participating provider or facility that submits the prior 10
authorization request through a process other than an electronic 11
prior authorization process described in subsection (2) of this 12
section: 13
(i) For nonelectronic standard prior authorization requests, the 14
managed care organization shall make a decision and notify the 15
provider or facility of the results of the decision within five 16
calendar days of submission of a nonelectronic prior authorization 17
request by the provider or facility that contains the necessary 18
information to make a determination. If insufficient information has 19
been provided to the managed care organization to make a decision, 20
the managed care organization shall request any additional 21
information from the provider or facility within five calendar days 22
of submission of the nonelectronic prior authorization request.23
(ii) For nonelectronic expedited prior authorization requests, 24
the managed care organization shall make a decision and notify the 25
provider or facility of the results of the decision within two 26
calendar days of submission of a nonelectronic prior authorization 27
request by the provider or facility that contains the necessary 28
information to make a determination. If insufficient information has 29
been provided to the managed care organization to make a decision, 30
the managed care organization shall request any additional 31
information from the provider or facility within one calendar day of 32
submission of the nonelectronic prior authorization request.33
(c) In any instance in which a managed care organization has 34
determined that a provider or facility has not provided sufficient 35
information for making a determination under (a) and (b) of this 36
subsection, a managed care organization may establish a specific 37
reasonable time frame for submission of the additional information. 38
This time frame must be communicated to the provider and enrollee 39
p. 12 HB 1706
with a managed care organization's request for additional 1
information. 2
(d) The prior authorization requirements of the managed care 3
organization must be described in detail and written in easily 4
understandable language. The managed care organization shall make its 5
most current prior authorization requirements and restrictions, 6
including the written clinical review criteria, available to 7
providers and facilities in an electronic format upon request. The 8
prior authorization requirements must be based on peer-reviewed 9
clinical review criteria. The clinical review criteria must be 10
evidence-based criteria and must accommodate new and emerging 11
information related to the appropriateness of clinical criteria with 12
respect to black and indigenous people, other people of color, 13
gender, and underserved populations. The clinical review criteria 14
must be evaluated and updated, if necessary, at least annually.15
(2)(a) Each managed care organization shall ((build and maintain 16
a prior authorization application programming interface that 17
automates the process for in-network providers to determine whether a 18
prior authorization is required for health care services, identify 19
prior authorization information and documentation requirements, and 20
facilitate the exchange of prior authorization requests and 21
determinations from its electronic health records or practice 22
management system. The application programming interface must support 23
the exchange of prior authorization requests and determinations for 24
health care services beginning January 1, 2025, and must:25
(i) Use health level 7 fast health care interoperability 26
resources in accordance with standards and provisions defined in 45 27
C.F.R. Sec. 170.215 and 45 C.F.R. Sec. 156.22(3)(b);28
(ii) Automate the process to determine whether a prior 29
authorization is required for durable medical equipment or a health 30
care service;31
(iii) Allow providers to query the managed care organization's 32
prior authorization documentation requirements;33
(iv) Support an automated approach using nonproprietary open 34
workflows to compile and exchange the necessary data elements to 35
populate the prior authorization requirements that are compliant with 36
the federal health insurance portability and accountability act of 37
1996 or have an exception from the federal centers for medicare and 38
medicaid services; and39
p. 13 HB 1706
(v) Indicate that)) establish and maintain a prior authorization 1
application programming interface that is consistent with final rules 2
issued by the federal centers for medicare and medicaid services and 3
published in the federal register, and that indicates that a prior 4
authorization denial or authorization of a service less intensive 5
than that included in the original request is an adverse benefit 6
determination and is subject to the managed care organization's 7
grievance and appeal process under RCW 48.43.535. The implementation 8
of the application programming interface must align with federal 9
effective dates, including enforcement delays and suspensions, issued 10
by the federal centers for medicare and medicaid services.11
(b) Each managed care organization shall establish and maintain 12
an interoperable electronic process or application programming 13
interface that automates the process for in-network providers to 14
determine whether a prior authorization is required for a covered 15
prescription drug. The interoperable electronic process or 16
application programming interface must support the exchange of prior 17
authorization requests and determinations for prescription drugs, 18
including information on covered alternative prescription drugs, 19
beginning January 1, 2027, and must: 20
(i) Allow providers to identify prior authorization information 21
and documentation requirements; 22
(ii) Facilitate the exchange of prior authorization requests and 23
determinations from its electronic health records or practice 24
management system ((, and may include the necessary data elements to 25
populate the prior authorization requirements that are compliant with 26
the federal health insurance portability and accountability act of 27
1996 or have an exception from the federal centers for medicare and 28
medicaid services)); and 29
(iii) Indicate that a prior authorization denial or authorization 30
of a drug other than the one included in the original prior 31
authorization request is an adverse benefit determination and is 32
subject to the managed care organization's grievance and appeal 33
process under RCW 48.43.535. 34
(c) If federal rules related to standards for using an 35
application programming interface to communicate prior authorization 36
status to providers are not finalized by September 13, 2023, the 37
requirements of (a) of this subsection may not be enforced until 38
((January 1, 2026 )) final rules published by the federal government 39
take effect. 40
p. 14 HB 1706
(((d)(i) If a managed care organization determines that it will 1
not be able to satisfy the requirements of (a) of this subsection by 2
January 1, 2025, the managed care organization shall submit a 3
narrative justification to the authority on or before September 1, 4
2024, describing:5
(A) The reasons that the managed care organization cannot 6
reasonably satisfy the requirements;7
(B) The impact of noncompliance upon providers and enrollees;8
(C) The current or proposed means of providing health information 9
to the providers; and10
(D) A timeline and implementation plan to achieve compliance with 11
the requirements.12
(ii) The authority may grant a one-year delay in enforcement of 13
the requirements of (a) of this subsection (2) if the authority 14
determines that the managed care organization has made a good faith 15
effort to comply with the requirements.16
(iii) This subsection (2)(d) shall not apply if the delay in 17
enforcement in (c) of this subsection takes effect because the 18
federal centers for medicare and medicaid services did not finalize 19
the applicable regulations by September 13, 2023.))20
(3) Nothing in this section applies to prior authorization 21
determinations made pursuant to RCW 71.24.618 or 74.09.490.22
(4) For the purposes of this section: 23
(a) "Expedited prior authorization request" means a request by a 24
provider or facility for approval of a health care service or 25
prescription drug where: 26
(i) The passage of time: 27
(A) Could seriously jeopardize the life or health of the 28
enrollee; 29
(B) Could seriously jeopardize the enrollee's ability to regain 30
maximum function; or 31
(C) In the opinion of a provider or facility with knowledge of 32
the enrollee's medical condition, would subject the enrollee to 33
severe pain that cannot be adequately managed without the health care 34
service or prescription drug that is the subject of the request; or35
(ii) The enrollee is undergoing a current course of treatment 36
using a nonformulary drug. 37
(b) "Standard prior authorization request" means a request by a 38
provider or facility for approval of a health care service or 39
prescription drug where the request is made in advance of the 40
p. 15 HB 1706
enrollee obtaining a health care service or prescription drug that is 1
not required to be expedited. 2
--- END ---
p. 16 HB 1706