Administrative Requirements

Time frames

Prior authorization requests may be submitted at any time, including outside normal business hours. While insurance carriers and third-party administrators must accept requests at all times, they are not required to start their review until their regular business hours resume. At that point, the following time frames are in effect and must be met.

Starting on Jan. 1, 2024:

Standard electronic prior authorization requests
For a standard electronic prior authorization request, an insurer must make a decision within three calendar days. If additional information is needed to make a determination, the health carrier must request it within one calendar day of the submission of the request.

Expedited electronic prior authorization requests
For an expedited electronic prior authorization request, an insurer must make a decision within one calendar days. If additional information is needed to make a determination, the health carrier must request it within one calendar day of the submission of the request.

Standard nonelectronic prior authorization requests
For a standard nonelectronic prior authorization request, an insurer must make a decision within five calendar days. If additional information is needed to make a determination, the health carrier must request it within five calendar days of the submission of the request.

Expedited nonelectronic prior authorization requests
For an expedited nonelectronic prior authorization request, an insurer must make a decision within two calendar days. If additional information is needed to make a determination, the health carrier must request it within one calendar day of the submission of the request.

Insurance carriers can establish reasonable time frames for the submission of additional information if they determine the physician or clinic did not submit sufficient information for the carrier to make an accurate determination.

Standard requests are made before a patient receives a service.

An expedited prior authorization should be used when, in the professional judgment of a physician, the time it would take to get a standard prior authorization would seriously jeopardize the life or health of an enrollee, seriously jeopardize the ability of the patient to regain maximum function, or the time it would take to receive a standard request would subject their patient to severe pain that cannot be managed without the service in question.

Online prior authorization: Moving away from inefficient technology

Insurers and third-party administrators are required to provide a secure, online process (such as a web-based online portal) for physicians to submit a prior authorization request.

While this online option must be offered in addition to other current methods, such as fax machines and 800 numbers, the goal of this provision is to move the industry away from reliance on outdated, inefficient technology.

This provision does not apply to integrated delivery systems.

Electronic standards: Building prior authorization into clinical workflows

Effective Jan. 1, 2026, carriers must build and maintain a prior authorization application programming interface or interoperable electronic process that automates for in-network providers the prior authorization process via electronic health records or practice management system.

The new application programming interface requirement will facilitate the process for determining the necessity of a prior authorization, provide information on documentation requirements, and assist with communications between a carrier and the provider or facility, such as requests and determinations.

Additional details on new electronic standards are forthcoming.

Emergency services

No prior authorization is needed for emergency services. The Office of the Insurance Commissioner clarifies that under current law, insurance carriers and third-party administrators are not permitted to require prior authorization for emergency services as defined at RCW 48.43.093.

Extenuating circumstances

No prior authorization is needed for “extenuating circumstances.” Extenuating circumstances are unforeseen situations where the timeframes for both standard and expedited prior authorization are insufficient for a physician to receive approval prior to the delivery of a service.

The Office of the Insurance Commissioner provides the following examples of “extenuating circumstances”:

  • A participating physician or facility is unable to identify from which carrier or its designated or contracted representative to request a prior authorization.
  • A participating physician or facility is unable to anticipate the need for a prior authorization before or while performing a service.
  • An enrollee is discharged from a facility and insufficient time exists for institutional or home health care services to receive approval prior to delivery of the service.

When an insurance carrier or third-party administrator is notified of an extenuating circumstance by a physician or facility (either at the time of claim submission or at the initiation of an appeal) the insurance carrier or third-party administrator must process the claim or appeal without a requirement for prior authorization.

Insurance carriers and third-party administrators must have an “extenuating circumstances” provision in their prior authorization program. Insurance carriers and third-party administrators may require physicians and facilities to follow certain policies and procedures for ordering services that qualify for an extenuating circumstance, such as documentation or timeframes for claim submission. These requirements must be posted online. Claims and appeals may still be reviewed for appropriateness, level of care, effectiveness, benefit coverage, and medical necessity under the criteria of the patient’s plan.

Approval expiration

Prior authorization determinations are guaranteed for at least 45 days from the date of approval.

Retroactive denials

Insurance carriers are prohibited from retrospectively denying a prior authorization it has already granted, as provided for at RCW 48.43.525.

Communication and Other Program Requirements

Determinations

When responding to a prior authorization request, an insurance carrier or third-party administrator must clearly state in their response if the service is approved or denied.

If the request is denied:

  • The response must give the specific reason for the denial in “clear and simple” language. If the request is denied based on medical necessity, the criteria used to make the determination must be given.
  • A written notice of a determination should be communicated to the physician, facility, and the patient.
  • If an insurance carrier or third-party administrator provides a decision orally, subsequent written notice must be provided.
  • A denial must include the department, credentials and phone number of the individual who has the authorizing authority to approve or deny the request.
  • A notice regarding an enrollee’s appeal rights must also be included in the communication.

If the request is approved:

  • Approval notifications must inform the requesting physician or the facility and the patient whether the approval is for a specific physician or other provider, or facility.
  • The approval must also state if the authorized service may be delivered by an out-of-network physician or facility, and if so, disclose to the patient the financial implications for receiving services from an out-of-network physician or facility.

While stopping short of mandating certain communication methods, the Office of the Insurance Commissioner clarifies that insurance carriers and third-party administrators must communicate in a way that is transparent and auditable. Physicians may negotiate with insurance carriers during the contracting process to ensure notification by a certain method.

Medical record requests and documentation

Insurance carriers and third-party administrators must provide to physicians a process to submit medical records and supporting documentation.

For medical record requests:

  • Insurance carriers and third-party administrators may only require the portion of the record necessary for the specific request to be determined.
  • Insurance carriers and third-party administrators must accept any evidence-based information from the physician that will assist in the determination process.

For supporting documentation:

  • Insurance carriers and third-party administrators must maintain a system of documenting and filing this information until the claim has been adjudicated or the appeals process has been finalized.
  • When requested by a physician, insurance carriers and third-party administrators must affirm that they received documents.

Under current law, insurance carriers must reimburse for medical record duplication.

Prior authorization program staff requirements

Under current law (RCW 48.43.016), an insurance carrier’s prior authorization program must be staffed by health care professionals who are licensed, certified, or registered, are in good standing, and must be in the same or related field as the physician who submitted the request, or of a specialty whose practice entails the same or similar covered health care service.

A denial must include the department and credentials of the individual who has the authorizing authority to approve or deny the request and must also include the phone number to contact the authorizing authority and a notice regarding an enrollee’s appeal rights.

Accreditation

The prior authorization program of an insurance carrier or third-party administrator must meet the standards set forth by a national accreditation organization, including (but not limited to):

  • National Committee for Quality Assurance
  • URAC
  • Joint Commission
  • Accreditation Association for Ambulatory Health Care

While insurance carriers and third-party administrators must adhere to the standards set forth by an accrediting organization, they are not required to receive the actual accreditation.

Out-of-network care

Insurance carriers and third-party administrators must have a process that permits out-of-network physicians and facilities to access preservice requirements and request a prior authorization. This provision does not apply to integrated delivery systems.

Approval notifications must state if the authorized service may be delivered by an out-of-network physician or facility, and if so, disclose to the patient the financial implications for receiving services from an out-of-network physician.

Appeals

The results of a prior authorization decision are not final; physicians and other facilities have the ability to appeal a prior authorization denial. A physician can file an appeal of a prior authorization denial without written permission of the patient.

Advanced authorization for diagnostic or lab services

To prevent patients from traveling long distances only to be evaluated and sent home to wait for authorization of a required service, specialists must be permitted by insurance carriers and third-party administrators to request a prior authorization for a diagnostic or laboratory service based upon advanced review of the medical record, so that appropriate services can be delivered at the initial appointment.

Facility-to-facility transports

According to the Office of the Insurance Commissioner, most requests for non-emergency single ambulance transports occur with little or no notice to ambulance providers. Retrospective review is provided for facility-to-facility ambulance transport so that ambulance providers may be reimbursed for their services if the patient’s plan includes coverage of that service.

If timeframes allow for a prior authorization, referring physicians are responsible for the request.

Changes to prior authorization program requirements

The Office of the Insurance Commissioner recognizes the challenges created for physicians when insurance carriers change their prior authorization program’s requirements with little or no notice.

Under existing law, changes that affect a physician’s or facility’s compensation or health care service delivery must be given 60-days prior notice. This includes changes to prior authorization programs.

Insurance carriers and third-party administrators must give physicians 60-days prior notice before making any changes to its prior authorization program, including the addition of new prior authorization requirements to services or changes to the clinical criteria used to consider prior authorization requests.

Continuity of care during market withdrawal

When an enrollee must change plans due to an insurance carrier’s market withdrawal, the new insurance carrier or third-party administrator must honor the prior authorization of the previous insurance carrier and ensure the patient receives the previously authorized service as an in-network service.

When an unexpected market withdrawal occurs, the new insurance carrier or third-party administrator must recognize a prior authorization for medical services for at least thirty days or the expiration date of the original prior authorization, whichever is shorter.

Transparency Requirements

Patient-specific information for determination

Insurance carriers and third-party administrators must have available for physicians a “current and accurate online prior authorization process” (such as a web-based online portal) that provides the patient-specific information needed to determine if a service is a benefit under the enrollee’s plan and the information necessary to submit a complete prior authorization request. The online process must provide information required for a physician to determine, for a specific patient’s plan, and for a specific service:

  • If the service is a benefit.
  • If prior authorization request is necessary.
  • What, if any, preservice requirements apply.
  • If a prior authorization is required, the following information:
    • The clinical criteria used to evaluate the request.
    • Any required documentation.

Insurance carriers and third-party administrators need not update the “current and accurate” online system in real-time; overnight updating is sufficient.

Integrated delivery systems are not required to comply with this provision for their physician employees participating through the integrated delivery system.

Clinical review criteria

Insurance carriers’ prior authorization requirements must be described in detail and written in easily understandable language. Additionally, carriers must make their most current prior authorization requirements and restrictions, including the written clinical review criteria, available to providers and facilities in an electronic format upon request.

Prior authorization requirements must be based on peer-reviewed clinical review criteria. The clinical review criteria must be evidence-based criteria and must accommodate new and emerging information related to the appropriateness of clinical criteria with respect to black and indigenous people, other people of color, gender, and underserved populations. The clinical review criteria must also be evaluated and updated, if necessary, at least annually.

According to the Office of the Insurance Commissioner, access to prior authorization criteria can be restricted to only participating physicians and facilities via a password-protected website and limited to the criteria of the service in question, but there are no exceptions for proprietary criteria.

Clinical review criteria used to evaluate requests for services must be provided to physicians and facilities before submitting a request, per the patient-specific information for determination discussed above.

If a request is denied, the response from the insurance carrier or third-party administrator must give the specific reason for the denial in “clear and simple” language. If the request is denied based on clinical review criteria, the criteria used to make the determination must be provided.

A prior authorization program must have staff who are properly qualified, trained, supervised, and supported by explicit written, current clinical review criteria and review procedures.

Documentation retention system

Insurance carriers and third-party administrators must maintain a system of documenting information and supporting evidence submitted by physicians. This information must be kept on file until the claim has been paid or the appeals process has been finalized.