This bill reenacts and amends RCW 48.43.830 and amends several related sections to increase transparency and accountability for prior authorization of health care services and prescription drugs. It imposes statutory timelines for prior authorization decisions and notices (electronic standard 3 days, electronic expedited 1 day; nonelectronic standard 5 days, nonelectronic expedited 2 days, with specified time limits for requests for additional information), requires carriers and certain health plans to make current prior authorization requirements and written clinical review criteria available electronically, and requires those criteria to be peer‑reviewed, evidence‑based, updated at least annually, and to consider equity and underserved populations. The amendments require that only a licensed physician or qualified licensed health professional may deny prior authorization based on medical necessity and that denial notices identify the credentials and specialties of the clinician with clinical oversight. The bill adds procedural safeguards for use of artificial intelligence (AI) in prior authorization: AI cannot be the sole means to deny, delay, or modify services; AI determinations must be based on the enrollee’s individual medical/clinical history and circumstances (not solely on group data), comply with state and federal law, be subject to periodic review and audit by the Office of the Insurance Commissioner under chapter 48.37 RCW, and limit patient data use consistent with chapter 70.02 RCW and HIPAA. It requires carriers and public employee health plans to establish interoperable prior authorization application programming interfaces (APIs) consistent with final CMS rules and an electronic prior authorization process for prescription drugs that supports exchange with EHRs; the API and interoperable exchange requirements must be implemented and enforced beginning January 1, 2027 regardless of subsequent CMS rule status, and after December 30, 2030 any new application of prior authorization must be available on the carrier’s electronic prior authorization system or API. The section excludes certain prior authorization determinations identified by statute (e.g., RCW 48.43.761 and RCW 41.05.526). The bill also changes appeal and review procedures: it prohibits retrospective denials or reductions of coverage for care that had prior authorization under the plan’s written policies except for material misrepresentation or lawful rescission, requires carriers to pay claims found to be valid and to assess interest at 1% per month retroactive to claim submission, and allows enrollee access to independent review organization (IRO) decisions without exhausting certain grievance timelines. It establishes IRO procedures and timelines (expedited external review within 72 hours, carrier document production to IRO within three business days, enrollee five business days to submit additional information, commissioner rotational registry of IROs, and standards for IRO decisionmaking) and requires carriers meeting a market threshold to report aggregated, deidentified prior authorization data (including top procedure/drug codes and average decision times) for the commissioner to publish annual reports. Several provisions in the extracted text are incomplete or cut off (including parts of the AI requirements, some API details, and the full text of the cited amendments and effective/expiration provisions), so the summary is limited to the material expressly provided.

If enacted, insurers and any companies they contract with to make prior authorization decisions will have to process requests much faster, post clear clinical criteria, and provide providers with electronic access to prior authorization requirements and decisions. Carriers must build or maintain APIs and interoperable systems so providers can check whether a prescription needs prior authorization and submit requests electronically by January 1, 2027 regardless of federal CMS rule timing; they also must limit the use of artificial intelligence so that denials for medical necessity are not made without a licensed clinician’s review and must meet audit, nondiscrimination, and data‑use safeguards. The bill also tightens protections for enrollees and providers by restricting retrospective denials, strengthening independent external review timelines and procedures, and requiring carriers to report detailed prior authorization metrics to the insurance commissioner, who will publish aggregated, deidentified summaries. Most of the practical costs and new duties fall on carriers and delegated health care benefit managers, which will likely need to invest in IT (APIs/interoperability), revise and annually update clinical review criteria, implement AI governance and audit processes, comply with faster turnaround clocks, and supply detailed data to regulators; carriers will also bear IRO fees and may owe interest on claims when authorizations are deemed valid. Providers will get faster, clearer responses but must meet new submission timelines and may need to provide information more quickly. Some important implementation details and exact reporting start dates, several AI provisions, and certain section effective/expiration specifics are incomplete in the provided text, so the precise scope and timing of some obligations remain uncertain.