CurrentWashington Office of the Insurance CommissionerPolicy N/A

Prior authorization and drug utilization review (DUR) rules (Chapter 284-43 WAC)

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Sets Washington state administrative requirements for prior authorization processes and prescription drug utilization review programs for health benefit plans, limited health care contracts, and stand-alone dental and vision plans; affects carriers, their vendors/contractors, participating providers, pharmacies, and enrollees in Washington.

Policy Summary

PayerWashington Office of the Insurance Commissioner

PolicyPrior authorization and drug utilization review (DUR) rules (Chapter 284-43 WAC)

Policy CodePolicy N/A

Change TypeRegulatory rulemaking (administrative update)

Effective DateDec 27, 2024

Next Review DateN/A

Key ActionProviders must be able to submit prior authorization requests at any time and carriers must provide secure online and other submission methods.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

284-43-2020; 284-43-2050WAC sections amended

31 daysEffective timing after filing

Jan 1, 2018Prior auth applicability date

Nov 1, 2019Required online process effective

45 daysMin prior auth expiration

Prior Authorization and DUR Requirements

Carrier and issuer prior authorization and drug utilization review obligations

Carrier and issuer obligations for prior authorization and drug utilization review — covered when the following organizational, procedural, and timeframe requirements are met:

Issuers must maintain a documented drug utilization review (DUR) program meeting RCW 48.43.400 and 48.43.410; the program must include methods to review and update criteria, meet national accreditation standards, and have properly qualified, trained, supervised staff supported by written clinical review criteria and procedures.

DUR clinical review criteria and the drug utilization management exception process must be posted and accessible to providers and enrollees in plain language; entities administering prescription drug benefits on an issuer's behalf must also post these items for the issuer's enrollees.

Prior authorization programs must be documented, use evidence-based clinical review criteria consistent with the enrollee's plan medical necessity definition, include a method for reviewing and updating criteria, and carriers remain responsible for compliance even when using third-party contractors.

Carriers must provide a secure online prior authorization process (effective Nov 1, 2019) accessible to participating providers and facilities that, prior to service delivery, discloses whether a service is a benefit, whether prior authorization is required, any preservice requirements, required documentation, and the clinical review criteria used.

Carriers must allow providers or facilities to submit prior authorization requests at all times, including outside normal business hours, and must provide a method for out-of-network providers/facilities to request prior authorization.

Carriers must document and retain information and supporting evidence submitted during prior authorization processing until the claim is paid or appeals are exhausted; when information is transmitted telephonically, provide written acknowledgment; upon request, remit written acknowledgment of receipt of each submitted document.

When a request lacks necessary information, the carrier/issuer must inform the provider or enrollee what additional information is needed and the deadline for submission; timeframes pause until receipt of necessary information or the deadline expires and then the applicable timeframes apply.

Notification and content requirements: determinations must be communicated to providers/facilities and enrollees within the applicable timeframes; denials must state specific reasons in clear language, include clinical review criteria if relied upon, identify the department and credentials of the authorizing individual, provide a contact phone number, and include notice of appeal rights and process.

Prior authorization approvals must state whether authorization is for a specific provider or facility, whether the service may be delivered by an out-of-network provider or facility, and disclose the enrollee's financial implications for out-of-network delivery; providers may appeal denials to the carrier.

Carriers must accept evidence-based information from providers and request only the sections of medical records necessary to determine medical necessity or appropriateness of the requested service.

Prior authorization and DUR timeframes (apply as specified):

Prescription drug urgent (urgent care review requests): issuer must approve or deny within 48 hours if sufficient; if insufficient, request additional information within 24 hours; provider has 48 hours to respond; issuer must then approve or deny within 48 hours of receipt.
Prescription drug nonurgent: approve or deny within 5 calendar days if sufficient; if insufficient, request additional information within 5 days; provider has 5 days to respond; issuer then approve or deny within 4 calendar days of receipt.
Health plan prior authorization per RCW 48.43.830 (decision after receipt of necessary information): electronic standard — decision and notification within 3 calendar days; electronic expedited — within 1 calendar day; nonelectronic standard — within 5 calendar days; nonelectronic expedited — within 2 calendar days.

Prior authorization determinations shall expire no sooner than 45 days from date of approval; for medical services carriers must recognize a prior authorization for at least 30 days or the original expiration date, whichever is shorter; in certain market-withdrawal circumstances the subsequent carrier must recognize prior authorizations until its process is completed.

Predetermination notices must clearly state they are not prior authorizations, be delivered within five calendar days of receipt, and disclose the same information required for prior authorization notices including clinical review criteria and any required documentation; whenever relating to a protected individual carriers must follow RCW 48.43.505.

Pharmacies must not be penalized or threatened for disputing coverage or payment determinations under drug utilization programs and carriers must ensure delegated entities post and make accessible clinical review criteria and exception processes for the issuer's enrollees.

Codes and Timelines

Neutral codesmixed

Prior authorization decision timeframes (electronic/nonelectronic standard and expedited timelines)

Electronic standard timeframeCarrier must decide and notify provider/facility within 3 calendar days of receiving necessary information (excludes holidays).

Electronic expedited timeframeCarrier must decide and notify provider/facility within 1 calendar day of receiving necessary information.

Nonelectronic standard timeframeCarrier must decide and notify provider/facility within 5 calendar days of receiving necessary information.

Nonelectronic expedited timeframeCarrier must decide and notify provider/facility within 2 calendar days of receiving necessary information.

Effect of insufficient informationIf carrier requests additional information, the applicable timeframes start once the carrier has the necessary information to make a determination.

Submitting Requests, Incomplete Info, and Denials

Prior Authorization

Submitting prior authorization requests

Providers and facilities must be able to submit prior authorization requests at any time, including outside normal business hours. Carriers (or their designated/contracted representatives) must provide a secure online process for participating providers or facilities to complete prior authorization requests and upload documentation (effective November 1, 2019). Carriers must also maintain a system documenting information and supporting evidence submitted during prior authorization requests and, upon request or when information is transmitted telephonically, provide written acknowledgments of receipt of documents or telephonic communications.

Allow submission of prior authorization requests at all times, including outside normal business hours.
Provide a secure online process for participating providers/facilities to complete requests and upload documentation (effective Nov. 1, 2019).
Document and retain all information and supporting evidence submitted while requesting prior authorization until claim paid or appeals exhausted.
Provide written acknowledgment of documents upon request and of telephonic transmissions.

Documentation Required

Handling requests with incomplete information

If a prior authorization request is missing necessary information, the carrier or its designated/contracted representative must inform the provider or facility what additional information is needed and the deadline for its submission. Time frames for determinations pause until the carrier has the necessary information to make a decision; once received (or the deadline for receipt expires), the applicable prior authorization time frames apply and the carrier must make a decision within the required period.

Inform the provider/facility what additional information is needed and the submission deadline when a request lacks necessary information.
Determination time frames are suspended until the carrier receives the necessary information; once received (or the deadline passes), the initial statutory time frames govern.

Denial Risk

Denial notification requirements

When a prior authorization request is denied, the carrier must state whether it is approved or denied and, for denials, provide the specific reason in clear and simple language. The denial must include clinical review criteria if the denial is based on those criteria, the department and credentials of the individual with authorizing authority, a phone number to contact that authorizing authority, and notice of the enrollee's appeal rights and process; written notice must be provided to the provider/facility and the enrollee (oral decision permitted if followed by written notice).

State approval or denial; for denials, give the specific reason in clear and simple language.
Provide clinical review criteria when the denial is based on those criteria.
Include the department and credentials of the authorizing individual and a contact phone number.
Provide notice of the enrollee's appeal rights and process and deliver written notice to the provider/facility and enrollee (oral allowed if followed by written).

Key Definitions for Review Requests

Definition of 'Urgent care review request' — clinical threshold for urgency

DefinitionAn 'Urgent care review request' is any request where delay could seriously jeopardize life or health, seriously jeopardize ability to regain maximum function, or, per a provider with knowledge of the patient's condition, subject the patient to severe pain that cannot be adequately managed without the requested care or treatment.

ScopeApplies to prescription drug utilization management timelines under WAC 284-43-2020.

Implication for timeframesUrgent drug requests are subject to shortened DUR timelines (e.g., 48-hour decision standards described elsewhere in the rule).

Definition of 'Nonurgent review request' — scope and use for prescription drug utilization review

DefinitionA 'Nonurgent review request' is any request for approval of care or treatment, or renewal of a previously approved request, that is not an urgent care request.

Use caseUsed to determine applicable prescription drug utilization management timelines separate from urgent requests.

Timeframe implicationNonurgent prescription drug requests follow standard DUR timelines (e.g., 5 calendar days for initial decision if sufficient information).

Definition of 'Electronic / Nonelectronic prior authorization request' — what qualifies as electronic prior authorization and system requirements

Electronic prior authorization requestA prior authorization delivered through a two-way communication system that meets requirements of a secure online prior authorization process or an interoperable electronic process or prior authorization application programming interface.

Nonelectronic prior authorization requestAny prior authorization request not delivered electronically, including but not limited to requests via email, phone call, text message, fax, or U.S. mail.

System requirement for electronic PAMust be a two-way communication system meeting secure online or interoperable API requirements as defined in the rule.

Policy Summary

PayerWashington Office of the Insurance Commissioner

PolicyPrior authorization and drug utilization review (DUR) rules (Chapter 284-43 WAC)

Policy CodePolicy N/A

Change TypeRegulatory rulemaking (administrative update)

Effective DateDec 27, 2024

Next Review DateN/A

Key ActionProviders must be able to submit prior authorization requests at any time and carriers must provide secure online and other submission methods.

SourceLink

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Prior authorization and drug utilization review (DUR) rules (Chapter 284-43 WAC)

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Sign up for all Washington Office of the Insurance Commissioner policy alerts

Know when Washington Office of the Insurance Commissioner releases new policies or updates existing guidance.

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Prior Authorization and DUR Requirements

Carrier and issuer prior authorization and drug utilization review obligations

Carrier and issuer obligations for prior authorization and drug utilization review — covered when the following organizational, procedural, and timeframe requirements are met:

Carriers must accept evidence-based information from providers and request only the sections of medical records necessary to determine medical necessity or appropriateness of the requested service.

Prior authorization and DUR timeframes (apply as specified):

Prescription drug urgent (urgent care review requests): issuer must approve or deny within 48 hours if sufficient; if insufficient, request additional information within 24 hours; provider has 48 hours to respond; issuer must then approve or deny within 48 hours of receipt.
Prescription drug nonurgent: approve or deny within 5 calendar days if sufficient; if insufficient, request additional information within 5 days; provider has 5 days to respond; issuer then approve or deny within 4 calendar days of receipt.
Health plan prior authorization per RCW 48.43.830 (decision after receipt of necessary information): electronic standard — decision and notification within 3 calendar days; electronic expedited — within 1 calendar day; nonelectronic standard — within 5 calendar days; nonelectronic expedited — within 2 calendar days.

Codes and Timelines

Neutral codesmixed

Prior authorization decision timeframes (electronic/nonelectronic standard and expedited timelines)

Electronic standard timeframeCarrier must decide and notify provider/facility within 3 calendar days of receiving necessary information (excludes holidays).

Electronic expedited timeframeCarrier must decide and notify provider/facility within 1 calendar day of receiving necessary information.

Nonelectronic standard timeframeCarrier must decide and notify provider/facility within 5 calendar days of receiving necessary information.

Nonelectronic expedited timeframeCarrier must decide and notify provider/facility within 2 calendar days of receiving necessary information.

Effect of insufficient informationIf carrier requests additional information, the applicable timeframes start once the carrier has the necessary information to make a determination.

Submitting Requests, Incomplete Info, and Denials

Prior Authorization

Submitting prior authorization requests

Allow submission of prior authorization requests at all times, including outside normal business hours.
Provide a secure online process for participating providers/facilities to complete requests and upload documentation (effective Nov. 1, 2019).
Document and retain all information and supporting evidence submitted while requesting prior authorization until claim paid or appeals exhausted.
Provide written acknowledgment of documents upon request and of telephonic transmissions.

Documentation Required

Handling requests with incomplete information

Inform the provider/facility what additional information is needed and the submission deadline when a request lacks necessary information.
Determination time frames are suspended until the carrier receives the necessary information; once received (or the deadline passes), the initial statutory time frames govern.

Denial Risk

Denial notification requirements

State approval or denial; for denials, give the specific reason in clear and simple language.
Provide clinical review criteria when the denial is based on those criteria.
Include the department and credentials of the authorizing individual and a contact phone number.
Provide notice of the enrollee's appeal rights and process and deliver written notice to the provider/facility and enrollee (oral allowed if followed by written).