Maintain a documented prospective prior authorization and utilization review program

Prior authorization is a mandatory prospective process that carriers (or their designated/contracted representatives) require providers or facilities to follow to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness; issuers must maintain a documented utilization review/prior authorization program with written clinical review criteria based on reasonable medical evidence and meet national accreditation standards.

• Maintain documented utilization review/prior authorization program description and written clinical review criteria.
• Make clinical review criteria available to participating providers on request and ensure contractor compliance.
• Retain submitted information and supporting evidence until claim payment or appeals are exhausted.

Use secure online prior authorization and API access; disclose criteria and accept uploads

Provide and maintain a secure, accessible online prior authorization process that allows participating providers and facilities to determine benefit/authorization requirements and to submit requests and upload required documentation at any time; by Jan 21, 2027, establish and maintain a prior authorization API consistent with CMS final rules and use FHIR-based APIs for prescription‑drug medical benefit prior auth as required.

• Online process must disclose whether a service is a benefit, if prior authorization is required, applicable preservice requirements, the clinical review criteria used, and any required documentation.
• Allow out‑of‑network providers access to preservice requirements and ability to request prior authorization.
• Carriers must accept electronic submissions 24/7 and provide secure access to personally identifiable information.

Meet required prior authorization and predetermination turnaround times

Make prior authorization decisions within the statutory timeframes measured from receipt of the necessary information: electronic standard 3 calendar days, electronic expedited 1 day, nonelectronic standard 5 days, nonelectronic expedited 2 days; predetermination notices must be delivered within five calendar days and must state that predetermination is not a prior authorization.

• If insufficient information is requested, the timeframes begin when the carrier has the necessary information.
• Predetermination notices must state: "A predetermination notice is not a prior authorization and does not guarantee services will be covered," and disclose clinical review criteria and required documentation when applicable.
• Issuers must provide deadlines for submission of additional information when requesting it from providers.

Authorization (certification) is a carrier determination of clinical eligibility

An authorization or certification is the carrier's determination that an admission, extension of stay, or other health care service has been reviewed and, based on information provided, meets clinical requirements for medical necessity, appropriateness, level of care, or effectiveness.

Staff prior authorization operations to meet timeliness and urgent appointment standards

Ensure sufficient qualified staff and written procedures to provide timely prior authorization decisions and avoid delays detrimental to enrollees' health; urgent ambulatory appointments must be available within 48 hours without prior authorization (96 hours with authorization).

• Issuers must have written policies/procedures assuring timely reviews and second opinions.
• Where prior authorization is used, ensure staffing to meet urgent appointment standards and timelines.

Recognize step therapy as a drug utilization management prior authorization protocol

Step therapy (fail‑first) protocols are defined as drug utilization management prior authorization protocols that establish the sequence in which prescription drugs are covered for a medical condition and are subject to exception requests and review.

• Step therapy is an element of the drug utilization management prior authorization program.
• Carriers must permit exception requests to utilization management restrictions including step therapy.

Accept and decide exception requests (including step‑therapy exceptions) and permit therapeutic substitution

Operate an exception request process that permits urgent and nonurgent requests to waive utilization management restrictions (including step therapy), allows substitution coverage for specialty/nonspecialty drugs and off‑label uses (vaccines excluded), and considers compendia, literature, and prescriber documentation when granting exceptions.

• Permit exception requests when formulary tiering changes during the year or when a prescriber determines substitution is medically necessary.
• Grant an exception if submitted evidence shows intolerance/contraindication, lack of therapeutic efficacy, required dosage differs, prior trial failure or clinically predictable harm.
• Do not require a new exception for refills if prescriber continues and FDA approval persists, except limited off‑label refill rules.

Treat step therapy as an NQTL and perform required comparative analysis

Treat step therapy/fail‑first policies as nonquantitative treatment limitations (NQTLs) that must comply with federal parity rules; beginning Jan 1, 2027, plans must perform and document comparative analyses of NQTLs applied to MH/SUD benefits in accordance with 89 Fed. Reg. 77586 et seq.

• Fail‑first/step therapy protocols are listed as examples of NQTLs.
• Plans/issuers must perform and document a comparative analysis of the design and application of each NQTL for MH/SUD benefits per the federal guidance effective Jan 1, 2027.

Ensure NQTLs (including step therapy) are comparable and no more stringent for MH/SUD

Ensure any NQTL, including utilization management and step therapy, is comparable to and not more stringent for mental health/substance use disorder benefits than for medical/surgical benefits in the same classification; document the analyses and authorization rationale.

• Apply NQTLs in a manner that complies with the requirement that processes, strategies, evidentiary standards, and other factors be comparable and no more stringent for MH/SUD.
• Document the comparative analysis and retain authorization decision records as part of prior authorization documentation.

Apply medical necessity standards consistently but note independent review and appeal risk

Carriers may limit coverage to services that meet issuer standards for medical necessity, care management, and claims administration, but such determinations remain subject to parity and appeal; denials that are adverse benefit determinations may be appealed and are subject to independent review.

• Issuers may apply medical necessity standards when defining covered services; however adverse determinations (denial, reduction, termination, rescission, or failure to pay) are appealable.
• Independent review organizations' clinical reviewers may override plan medical necessity standards if those standards are unreasonable or inconsistent with evidence‑based practice.

Provide only necessary documentation; carriers must limit and reimburse record requests

Limit documentation requests to only information necessary to certify the admission, procedure, treatment, length of stay, or frequency/duration of services; for concurrent review request only the specific sections of the medical record necessary for that case.

• Accept evidence‑based information from providers to assist authorization.
• Do not routinely request full medical records; reimburse reasonable costs of medical record duplication for reviews.
• If medical records are requested, request only the sections necessary to determine medical necessity or appropriateness.

Publish clinical review criteria online and retain prior authorization records

Carriers must make the clinical review criteria and any required documentation information available through the online prior authorization process and must document and retain information and supporting evidence submitted during prior authorization until claim payment or appeals are exhausted.

• Provide clinical review criteria and required documentation via the online prior authorization portal.
• Upon provider request, remit written acknowledgments of receipt for submissions; when information is transmitted telephonically, provide written acknowledgment of the information communicated.

Scope prior authorization documentation requests to limited medical record sections

Carriers may request only information necessary to authorize the service; if medical records are requested, limit the request to the specific sections needed to determine medical necessity, admission/extension of stay, or frequency/duration of service.

• Base review determinations on the medical information available at the time of review.
• Provide clear notice when additional information is needed and set deadlines for submission.

Document NQTL comparative analyses and include authorization rationale

When applying any NQTL to MH/SUD benefits, perform and document a comparative analysis of the design and application of each NQTL per federal requirements; authorization determinations (medical necessity/level of care decisions) must be documented as part of that analysis.

• Comparative analysis must follow 89 Fed. Reg. 77586 et seq. (effective Jan 1, 2027) and be documented by plans/issuers.
• Include authorization determinations and the evidentiary basis used when documenting NQTL analyses.

Provide plan provisions and cooperate with IRO documentation requests

Independent review organizations may request additional plan provisions or the full health plan coverage agreement if necessary to provide adequate context; IRO clinical reviewers may overturn plan medical necessity standards if those standards are unreasonable or inconsistent with sound evidence‑based practice.

• IROs must ensure determinations are consistent with RCW standards and may interpret coverage provisions when clinical review requires it.
• Submit plan documents to IROs upon request to provide context for determinations.

Adverse determinations include denials, reductions, terminations, rescissions, and payment failures

An adverse determination includes carrier or delegated utilization review decisions that a request does not meet requirements for medical necessity, appropriateness, level of care, or effectiveness, or is experimental/investigational, and includes denials, reductions, terminations, rescissions, or failure to pay.

• Treat denials, reductions, terminations, rescissions, and payment failures based on utilization review determinations as adverse determinations subject to notice and appeal.
• Ensure adverse determination notices contain required content (see next block).

Do not use criteria more restrictive than age‑appropriate placement tools

Do not apply criteria that conflict with or are more restrictive than relevant age‑appropriate patient placement criteria (ASAM, LOCUS, CALOCUS‑CASII, ECSII); using such restrictive criteria may lead to adverse benefit determinations and must not be used to deny, restrict, or limit access to requested services.

• When placing service intensity or level of care, apply the listed age‑appropriate placement criteria and use additional criteria only to approve requested services.
• If carrier's application is inconsistent with requested placement, adverse determination notices must include full details of assessment and clinical review criteria applied.

Include specific reasons, clinical criteria, reviewer credentials, contact, and appeal info in denial notices

When a prior authorization is denied, the written notice to the provider and enrollee must state the specific reason for denial in clear, simple language; if based on clinical review criteria, provide those criteria; include the department and credentials of the person with authorizing authority, a contact phone number, and notice of the enrollee's appeal rights and process.

• The response may be provided orally but must be followed by written notice.
• For protected individuals, follow statutory special procedures (RCW 48.43.505).

Recognize the full set of triggers that create adverse determinations and appeal rights

Adverse determinations are triggered by denials, reductions, terminations, rescissions, failure to provide payment, or determinations based on eligibility, medical necessity, appropriateness, level of care, effectiveness, or experimental/investigational status; these outcomes are appealable and may prompt IRO review.

• Prospective and retrospective review decisions that deny, reduce, or terminate benefits are adverse determinations.
• Rescissions of coverage and denials of applications for coverage are included as adverse determinations.

Independent reviews can overturn unreasonable medical necessity standards — carriers face appeal/coverage risk

Independent review determinations must follow applicable RCW and WAC standards; clinical reviewers can overturn a plan's medical necessity or appropriateness standards if those standards are unreasonable or inconsistent with sound evidence‑based practice, creating potential medical necessity and coverage risk for the carrier.

• IRO determinations must be consistent with RCW 48.43.537, 48.43.535, 48.43.766 and chapter 284‑43A WAC.
• Clinical reviewers decide medical necessity based on expert judgment and relevant evidence and may interpret plan coverage provisions when needed.