Bill > SB5395

This bill aims to improve transparency and accountability in the prior authorization process for health insurance carriers, health plans, and managed care organizations. It introduces several key provisions to regulate how prior authorization decisions are made, with a particular focus on limiting the use of artificial intelligence (AI) in medical decision-making. The bill requires carriers to provide clear timelines for prior authorization requests, with specific response times for electronic and non-electronic submissions. Health plans must now include the credentials of the provider who made a prior authorization determination in their notifications. Beginning August 1, 2025, new prior authorization requirements can only be implemented quarterly, with advance notice to providers. The bill significantly restricts the use of AI in medical determinations, mandating that only licensed physicians or health professionals can deny prior authorization requests based on medical necessity, and that AI cannot be the sole means of making care decisions. Carriers must ensure any AI used in the process bases determinations on individual patient history, does not discriminate, and is subject to regular audits and reviews. Additionally, health plans must develop application programming interfaces to automate and streamline the prior authorization process, and they will be required to report detailed statistics about their prior authorization practices, including the percentage of denials aided by AI. The overall goal is to make the prior authorization process more transparent, fair, and patient-centered.

Budget and Finance, Health and Social Services

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