Prior Authorization Modernization — Implementation of E2SHB 1357 (Prior authorization timelines and program requirements)
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Proposed amendments to WAC Chapter 284-43 Subchapter D to implement RCW 48.43.830, updating prior authorization time frames and clarifying applicability and processes for health plans, prescription drugs, and limited benefit plans; affects carriers, issuers, providers, pharmacies, and participating facilities operating under Washington law.
Updates prior authorization time frames for health care services and prescription drugs to align with RCW 48.43.830, specifying electronic and nonelectronic standard and expedited decision timelines.
Clarifies that prior authorization program requirements (staffing, documentation, accreditation standards, online access, and recordkeeping) apply to carriers and their delegated entities, and carriers remain responsible even when using third-party vendors.
Separates prescription drug utilization management timelines from prescription drug prior authorization timelines and requires posting of clinical review criteria and exception processes online.
Prior Authorization Coverage Criteria & Timelines
Prior authorization program and timeline criteria
Requirements and criteria applicable to prior authorization programs and timelines for different plan types and submission methods.
ALL of the following
Electronic requests
- Electronic standard prior authorization requests: decision and notification within 3 calendar days of receiving the necessary information.
- Electronic expedited prior authorization requests: decision and notification within 1 calendar day of receiving the necessary information.
Nonelectronic requests
- Nonelectronic standard prior authorization requests: decision and notification within 5 calendar days of receiving the necessary information.
- Nonelectronic expedited prior authorization requests: decision and notification within 2 calendar days of receiving the necessary information.
Prior authorization operational criteria
Operational requirements and notices related to authorization decisions, expirations, and communications.
Coding, Modalities, and Decision Thresholds
Provider & Facility Actions Required
Provide secure online or interoperable electronic prior authorization access
Carriers must provide a secure online prior authorization process (or interoperable electronic process/API) accessible to participating providers and facilities that: shows whether a service is a benefit, whether a prior authorization is necessary, applicable preservice requirements, the clinical review criteria used to evaluate requests, allows submission of requests and upload of documentation, and accepts requests 24/7; electronic requests follow shorter decision timelines than nonelectronic requests.
- Online access must allow providers/facilities to determine benefit status and preservice requirements before delivering a service.
- The online process must permit submission of prior authorization requests and uploading of supporting documentation.
- Carriers must accept prior authorization requests at all times, including outside normal business hours.
Notify provider/facility when additional information is required
If a prior authorization request lacks necessary information, the carrier or its designated/contracted representative must inform the provider or facility what additional information is needed and the deadline for submission of that information.
- Carrier must notify the provider/facility which additional information is required.
- Carrier must state the deadline for submitting the required information.
Permit specialist-initiated prior authorization for diagnostics
Carriers must allow specialists to request prior authorization for diagnostic or laboratory services based on a review of medical records in advance of seeing the enrollee.
- Specialists may request authorization for diagnostics/labs using medical record review prior to patient visit.
- This requirement applies to the carrier or its designated/contracted representative's prior authorization process.
Allow post-service facility-to-facility transport authorizations
A prior authorization for facility-to-facility transport that requires authorization may be performed after the service is delivered; authorization may only be based on information available to the carrier or its designated/contracted representative at the time of the prior authorization request.
- Post-service transport authorizations are allowed when prior authorization is required.
- Authorization decisions must rely solely on information available at time of the request.
Predetermination notices must state they are not prior authorizations and include required content and timelines
When a plan provides predetermination requests, the carrier must offer a predetermination notice that clearly states it is not a prior authorization and does not guarantee coverage; predetermination notices must be delivered within five calendar days of receipt and disclose whether a service is a benefit, if a prior authorization is necessary, any preservice requirements, required documentation, and the clinical review criteria used.
- Notice must state: "A predetermination notice is not a prior authorization and does not guarantee services will be covered."
- Predetermination notices must be delivered within five calendar days of receipt of the request.
- Notices must disclose benefit status, whether prior authorization is necessary, preservice requirements, any required documentation, and the clinical review criteria used.
Key Definitions
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