Prior Authorization Modernization - Implementation of E2SHB 1357 (2023)
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Governs adoption and implementation of amendments to Washington Administrative Code Chapter 284-43 Subchapter D to implement E2SHB 1357 (2023), affecting carriers and other entities that administer prior authorization for health care services and prescription drugs in Washington state.
No material clinical or coverage changes in this revision.
Scope and Coverage Changes
Prior authorization and utilization management scope
The adopted rule updates and clarifies timeframes and scope for prior authorization and prescription drug utilization management.
Prior authorization updates (informational)
Summary of coverage-related rule changes
Amended WAC Sections / Coding Impact
| No codes listed |
Prior Authorization Timeframes & Applicability (Provider Actions)
Follow updated prior authorization timeframes and applicability standards
Adopted rule updates prior authorization timeframes for health care services and prescription drugs and clarifies which health plans and entities the rules apply to; providers must follow the updated timeframes in the amended WAC when submitting and responding to prior authorization requests.
- Ensure prior authorization requests and responses adhere to the updated timeframes in the amended WAC provisions.
- Be aware that the rule clarifies health plan applicability standards so affected entities understand their obligations.
Apply WAC 284-43-2020 to utilization management, not drug prior authorizations
WAC 284-43-2020 applies to prescription drug utilization management timelines other than prescription drug prior authorization timelines; providers and pharmacies must apply WAC 284-43-2050 for prescription drug prior authorization timelines instead.
- Do not treat prescription drug prior authorization timelines as governed by WAC 284-43-2020.
- Apply WAC 284-43-2020 only to utilization management activities (for example, concurrent or retrospective medical necessity assessments) that are not prior authorizations.
Comply with adopted prior authorization timeframes and expect OIC monitoring
The adopted rule updates prior authorization timeframes for health care services and prescription drugs and clarifies which health plans and entities are subject to those timeframes; providers must follow the adopted WAC provisions and OIC oversight as implemented.
- Follow the amended prior authorization timeframes for both health care services and prescription drugs as set forth in the adopted rule.
- Expect OIC monitoring of prior authorization timeframes through consumer complaints and investigations as described in the implementation plan.
Terminology and Purpose
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