Bill > SB5395

This bill aims to increase transparency and accountability in the prior authorization process, which is a requirement by health insurance carriers (companies that offer health plans) for certain medical services or prescription drugs before they are provided to ensure they are medically necessary and covered. The bill mandates that only licensed physicians or health professionals can deny a prior authorization request based on medical necessity, and that artificial intelligence (AI) cannot be the sole basis for denying, delaying, or modifying care, requiring human review for such decisions. It also establishes stricter timelines for carriers to make prior authorization decisions, with faster turnaround times for urgent requests and a requirement for clear, understandable documentation of prior authorization rules. Furthermore, the bill requires carriers to disclose the credentials of the providers who oversaw prior authorization denials and to post all changes to their prior authorization policies online. It also mandates that carriers develop interoperable electronic systems for determining prior authorization requirements and exchanging requests, and that they report detailed data on their prior authorization practices, including the use of AI and adherence to turnaround times. The bill also prohibits retrospective denials of services that were previously authorized, except in cases of material misrepresentation or lawful rescission of coverage, and applies these new rules to health plans for public employees and retirees.

Budget and Finance, Health and Social Services

https://app.leg.wa.gov/billsummary?BillNumber=5395&Year=2025&Initiative=false