Reducing the negative impact of insurance carrier prior authorization processes on Washington’s physicians, physician assistants, and patients continues to be a top priority of the Washington State Medical Association.

In 2023, the WSMA championed House Bill 1357, sponsored by Rep. Tara Simmons (D-Bremerton), to facilitate the transition to electronic prior authorization processes and shorten processing timelines across state-regulated insurance plans for both health care services and prescription drugs.

Beginning in 2024, Washington physicians can expect tighter turnaround times for prior authorization approvals and notifications as well as increased transparency around insurance carrier prior authorization programs. These changes are intended to reduce administrative burden for health professionals, generate significant cost savings, and improve patient health outcomes.

HB 1357 builds on WSMA advocacy at the state’s Office of the Insurance Commissioner where rulemaking was finalized in 2019 that intended to ease administrative burdens associated with health insurance carriers and their third-party administrators’ prior authorization of health care services and prescription drugs.

About the WSMA Prior Authorization Navigator

The WSMA originally introduced its Prior Authorization Navigator in 2018 as a mobile-friendly “one-stop shop” for guidance on existing and new state prior authorization requirements. To ensure our members reap full benefit of the WSMA’s recent advocacy work, in early 2024 we updated the Navigator to incorporate the new reforms contained in HB 1357 as well as the 2019 rulemaking.

What health plans are covered

The 2019 rulemaking and HB 1357 apply to plans regulated by the Office of the Insurance Commissioner:

  • Individual (both on and off the Washington Health Benefit Exchange).
  • Small group.
  • Large group (other than self-insured).

Filing a complaint

Insurers are obligated to ensure their third-party administrators comply with these new requirements. The Office of the Insurance Commissioner enforces its requirements using a complaint-driven process. If an insurer or third-party administrator is out of compliance with prior authorization requirements as described in the Navigator, file a complaint using the Navigator’s complaint form.

More Work to Be Done: Improving Prior Authorization Transparency and Accountability

During the 2025 state legislative session, the WSMA is working in coalition with the Washington State Hospital Association and Proliance Surgeons on legislation to improve transparency and accountability in the prior authorization process: Senate Bill 5395, sponsored by Sen. Tina Orwall (D-Des Moines), and House Bill 1566, sponsored by Rep. Alicia Rule (D-Blaine).

This year’s legislation would build upon recent reforms by:

  • Prohibiting artificial intelligence from being the sole means to deny a prior authorization, ensuring that any denial of a prior authorization request can only be made upon review by a licensed physician or health professional working within their scope of practice.
  • Clarifying current state law prohibiting retrospective denials, making it clear that retrospective denials of coverage due to a change in the carrier’s determination of medical necessity are prohibited. 
  • Clarifying that retrospective denials shall not be considered adverse benefit determinations subject to a carrier’s standard appeals process. This would increase awareness and accountability of current law and ensure prior authorization determinations and payment are not clawed back after the service has been provided.

The WSMA has been engaged in extensive negotiation with our partners, state agencies, and insurance carriers on both bills and will continue to prioritize this important issue before the Legislature. Stay tuned for updates.