This bill amends existing Washington statutes governing health plan prior authorization (including RCW 48.43.830 and related sections listed in the header) and creates new procedural and reporting requirements. It is mainly a set of procedural and compliance changes for carriers, managed care organizations (MCOs), and health plans rather than creation of a new criminal offense. It adds required timeframes for prior authorization decisions and notices for electronic and nonelectronic submissions, requires plans to publish prior authorization rules and clinical review criteria in electronic form, and mandates APIs and interoperability standards for automated prior authorization exchanges. Key legal changes include: specific decision-and-notification deadlines for electronic and nonelectronic standard and expedited requests; requirement that only a licensed physician or licensed health professional within scope may deny a prior authorization based on medical necessity after review of the provider recommendation and the enrollee’s clinical history; explicit limits on using artificial intelligence (AI) so that AI may not be the sole means to deny, delay, or modify care and AI-based decisions affecting medical necessity require specified safeguards (data based on the enrollee’s clinical history and individual circumstances, nondiscrimination, auditability, periodic review, and limits on data use consistent with HIPAA and state patient data law). Carriers and MCOs must build and maintain prior authorization APIs for services by January 1, 2025 and for prescription drugs by January 1, 2027 (with limited enforcement delays tied to federal CMS rule finalization), include clinical reviewer credentials in denial notices, and meet HL7 FHIR and other technical/functional requirements. The bill also changes remedies and reporting: it bars retrospective denials or reductions to a less intensive service when a valid prior authorization was in place (except for material misrepresentation or lawful rescission), requires interest at 1% per month when authorizations are later validated, expands annual aggregated deidentified reporting of prior authorization data beginning January 1, 2026, and authorizes the commissioner/authority to grant limited enforcement delays and adopt implementing rules. Important context is missing from the extracted text: some subsections and definitions are cut off, the identity of the referenced "authority" is not specified in these excerpts, and portions of the API and other provisions are incomplete in the provided material.

If enacted, the bill would force health insurers, managed care organizations, and any contractors making prior authorization decisions to act much faster and more transparently: set deadlines for electronic and paper requests (for example, 3 days for electronic standard requests, 1 day for electronic expedited requests, 5 days for nonelectronic standard, 2 days for nonelectronic expedited), publish clear clinical review criteria that are peer‑reviewed and updated at least annually, and post policy changes in a single online location with 45 days’ notice unless an FDA, NCCN, USPSTF update or public health emergency requires immediate change. Plans must build interoperable APIs to automate whether prior authorization is needed for services by Jan 1, 2025 and for prescription drugs by Jan 1, 2027, may not rely on AI as the sole basis to deny care (AI use must meet specified safeguards and be subject to audit), and only a licensed clinician may deny requests on medical necessity; carriers that retroactively deny valid authorizations generally must pay the claim and 1% interest per month. These changes will likely require insurers and delegated benefit managers to invest in technology, compliance, clinician review capacity, and data reporting, produce faster responses that providers must meet with complete documentation, and give enrollees clearer reasons and appeal paths for denials. The groups most affected are carriers/MCOs and any health care benefit managers (who will face new technical, staffing, audit, and reporting responsibilities and potential costs), in‑network providers (who will receive quicker decisions but must supply sufficient information promptly and adapt to APIs), and enrollees (who should see faster decisions, more transparency about who made denials, and stronger protections against retrospective denials). Important implementation details in the provided text are missing or incomplete — for example the identity of “the authority,” some cross‑referenced subsections, and portions of the API and AI safeguard language — so certain enforcement timing and operational requirements remain unclear from the excerpts available.