Bill > SB5395

This bill aims to improve transparency and accountability in how health insurance companies, referred to as "carriers," make decisions about prior authorization, which is the process of getting approval before receiving certain medical services or prescription drugs. It mandates that licensed physicians and health professionals, not artificial intelligence (AI) alone, must be responsible for denying or modifying prior authorization requests based on medical necessity, ensuring AI is used as a tool to assist, not solely to decide, and that its use is fair and doesn't discriminate. The bill also sets stricter timelines for carriers to respond to prior authorization requests, requires them to clearly publish their requirements, and ensures that when a request is denied, the credentials of the overseeing medical professional are provided. Furthermore, it prohibits carriers from retrospectively denying coverage for services that were previously approved through prior authorization, except in cases of material misrepresentation or lawful rescission of coverage, and it clarifies that certain appeals processes related to prior authorization denials do not require exhausting the carrier's internal grievance process first. Finally, the bill requires carriers to report detailed data on their prior authorization practices, including the use of AI in denials and adherence to response times, to the state insurance commissioner, with specific provisions for how this data is collected and reported.

Budget and Finance, Health and Social Services

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