HB 1706 — Aligning the implementation of application programming interfaces for prior authorization with federal guidelines.

H-1474.1H-0833.1 SUBSTITUTE HOUSE BILL 1706 State of Washington 69th Legislature 2025 Regular Session By House Health Care & Wellness (originally sponsored by Representative Simmons)Simmons READRead FIRSTfirst TIMEtime 02/21/25.01/29/25.

Referred to Committee on Health Care & Wellness.

1 SHBHB 1706 provided to the carrier to make a decision, the carrier shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.

2 SHBHB 1706 of the additional information.

3 SHBHB 1706 (v) Indicate that)) establish and maintain a prior authorization application programming interface that is consistent with final rules issued by the federal centers for medicare and medicaid services and published in the federal register, and that indicates that a prior authorization denial or authorization of a service less intensive than that included in the original request is an adverse benefit determination and is subject to the carrier's grievance and appeal process under RCW 48.43.535.

The implementation of the application programming interface must align with federal effective dates, including enforcement delays and suspensions, issued by the federal centers for medicare and medicaid services.

(c) ((If))If Regardless of whether federal rules related to standards for using an application programming interface to communicate prior authorization status to providers are revoked, delayed, suspended, or not finalized by the federal centers for medicare and medicaid services ((byby September 13, 2023))2023, after February 8, 2024, the requirements of (a) of this subsection ((maymay not))not shall be enforced ((until))until beginningp. January 1, ((2026)) 2027.

(d)(((i)4 IfHB a1706 carrier((January determines1, that2026)) itfinal willrules notpublished beby able to satisfy the requirementsfederal ofgovernment (a)take ofeffect. this subsection by January 1, p.

4(d)(((i) SHBIf 1706a carrier determines that it will not be able to satisfy the requirements of (a) of this subsection by January 1, 2025, the carrier shall submit a narrative justification to the commissioner on or before September 1, 2024, describing:

(4) For the purposes of this section:

(a) "Expedited prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where:

5 SHBHB 1706 (i)(4) TheFor passagethe purposes of time:this section:

(a) "Expedited prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where:

(i) The passage of time:

If insufficient information has been provided to the health plan to make a decision, the health plan shall p.

6 HB 1706 request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.

(ii) For electronic expedited prior authorization requests, the health plan shall make a decision and notify the provider or facility of the results of the decision within one calendar day of submission of an electronic prior authorization request by the provider or facility that contains the necessary information to make a determination.

p.

6 SHB 1706 (ii) For electronic expedited prior authorization requests, the health plan shall make a decision and notify the provider or facility of the results of the decision within one calendar day of submission of an electronic prior authorization request by the provider or facility that contains the necessary information to make a determination.

If insufficient information has been provided to the health plan to make a decision, the health plan shall request any additional information from the provider or facility within one calendar day of submission of the electronic prior authorization request.

(c) In any instance in which the health plan has determined that a provider or facility has not provided sufficient information for making a determination under (a) and (b) of this subsection, the health plan may establish a specific reasonable time frame for p.

7 SHBHB 1706 (c) In any instance in which the health plan has determined that a provider or facility has not provided sufficient information for making a determination under (a) and (b) of this subsection, the health plan may establish a specific reasonable time frame for submission of the additional information.

(iv) Support an automated approach using nonproprietary open workflows to compile and exchange the necessary data elements to populate the prior authorization requirements that are compliant with the federal health insurance portability and accountability act of p.

8 SHBHB 1706 (iv) Support an automated approach using nonproprietary open workflows to compile and exchange the necessary data elements to populate the prior authorization requirements that are compliant with the federal health insurance portability and accountability act of 1996 or have an exception from the federal centers for medicare and medicaid services;

The implementation of the application programming interface must align with federal effective dates, including enforcement delays and suspensions, issued by the federal centers for medicare and medicaid services.

and (iii) Indicate that a prior authorization denial or authorization of a drug other than the one included in the original prior authorization request is an adverse benefit determination and is subjectp. to the health plan's grievance and appeal process under RCW 48.43.535.

(c)9 ((If))HB Regardless1706 ofsubject whether federal rules related to standards for using an application programming interface to communicate prior authorization status to providers are revoked, delayed, suspended, or not finalized by the federalhealth centersplan's forgrievance medicare and medicaidappeal servicesprocess ((byunder SeptemberRCW 13,48.43.535. 2023)) after p.

9(c) SHBIf 1706federal Februaryrules 8,related 2024,to standards for using an application programming interface to communicate prior authorization status to providers are not finalized by the federal centers for medicare and medicaid services by September 13, 2023, the requirements of (a) of this subsection ((maymay not))not shall be enforced ((until))until beginning((January January 1, ((2026))2026)) 2027.final rules published by the federal government take effect.

or (C)p. In the opinion of a provider or facility with knowledge of the enrollee's medical condition, would subject the enrollee to severe pain that cannot be adequately managed without the health care service or prescription drug that is the subject of the request;

10 HB 1706 (C) In the opinion of a provider or facility with knowledge of the enrollee's medical condition, would subject the enrollee to severe pain that cannot be adequately managed without the health care service or prescription drug that is the subject of the request;

(b) "Standard prior authorization request" means a request by a provider or facility for approval of a health care service or p.prescription drug where the request is made in advance of the enrollee obtaining a health care service that is not required to be expedited.

10 SHB 1706 prescription drug where the request is made in advance of the enrollee obtaining a health care service that is not required to be expedited.

(ii) For electronic expedited prior authorization requests, the managed care organization shall make a decision and notify the provider or facility of the results of the decision within one calendarp. day of submission of an electronic prior authorization request by the provider or facility that contains the necessary information to make a determination.

11 HB 1706 calendar day of submission of an electronic prior authorization request by the provider or facility that contains the necessary information to make a determination.

p.(b) The managed care organization shall meet the following time frames for prior authorization determinations and notifications to a participating provider or facility that submits the prior authorization request through a process other than an electronic prior authorization process described in subsection (2) of this section:

11 SHB 1706 (b) The managed care organization shall meet the following time frames for prior authorization determinations and notifications to a participating provider or facility that submits the prior authorization request through a process other than an electronic prior authorization process described in subsection (2) of this section:

This time frame must be communicated to the provider and enrollee withp. a managed care organization's request for additional information.

12 HB 1706 with a managed care organization's request for additional information.

The p.prior authorization requirements must be based on peer-reviewed clinical review criteria.

12 SHB 1706 prior authorization requirements must be based on peer-reviewed clinical review criteria.