HB 1566 — Making improvements to transparency and accountability in the prior authorization determination process.

(a) "Artificial intelligence" means the use of machine learning and related technologies that use data to train statistical models for the purpose of enabling computer systems to perform tasks normally associated with human intelligence or perception, such as computer vision, speech or natural language processing, and content generation.

"Artificial intelligence" includes generative artificial intelligence.

(((b))) (c) "Standard prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where the request is made in advance of p.

8 SHBHB 1566 (((b)))the (c)enrollee "Generativeobtaining artificiala intelligence"health meanscare anservice artificialor intelligenceprescription systemdrug that generatesis novelnot datarequired orto contentbe basedexpedited. on a foundation model.

(d) "Machine learning" means the process by which artificial intelligence is developed using data and algorithms to draw inferences therefrom to automatically adapt or improve its accuracy without explicit programming.

(e) "Standard prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where the request is made in advance of the enrollee obtaining a health care service or prescription drug 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 calendar day of submission of an electronic prior authorization request by the provider or facility that contains the necessary p.information to make a determination.

9 SHB 1566 information to make a determination.

(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 priorp. authorization process described in subsection (((2))) (5) of this section:

9 HB 1566 prior authorization process described in subsection (((2))) (6) of this section:

p.(d) The prior authorization requirements of the managed care organization must be described in detail and written in easily understandable language.

10 SHB 1566 (d) The prior authorization requirements of the managed care organization must be described in detail and written in easily understandable language.

The clinical review criteria must be evidence-based criteria and must accommodate new and emerging information related to the appropriateness of clinical criteria with respectp. to black and indigenous people, other people of color, gender, and underserved populations.

10 HB 1566 respect to black and indigenous people, other people of color, gender, and underserved populations.

(((2))) (e) When denyingissuing a notification for a prior authorization determination, the managed care organization shalland includeany thecontracted credentials,health boardcare certifications,benefit andmanager areasshall ofinclude specialtya expertiseunique andidentifier trainingfor of the providerindividual who hadinitially clinicalreviewed oversight over the determination in any notification sent to the managed care enrollee and providermade requesting or referring the service.determination.

(2)(a)The Managedmanaged care organizationsorganization maintainshall also include the abilitynational toprovider makeidentification adjustmentsnumber toof policiesthe andphysician procedureswho thathad impactclinical oversight for the applicabilitydetermination as well as the physician's credentials, board certifications, and areas of theirspecialty priorexpertise authorizationand requirements.training in any notification sent to the managed care enrollee and provider requesting or referring the service.

Except(f) asIn providedthe incase (b) of thisan subsection,adverse beginningbenefit Augustdetermination, 1,a 2025,managed thesecare adjustmentsorganization canshall onlymake beavailable madeto quarterlythe andrequesting goprovider intoa effectpeer-to-peer eitherreview Januarydiscussion. 1st, April 1st, July 1st, or October 1st of any given calendar year.

NotificationThe ofpeer policyreviewer changesprovided mustby bethe providedmanaged tocare allorganization in-networkmust providerspossess ata leastcurrent 45and daysvalid priornonrestricted license to thepractice quarterlymedicine updatein Washington state and must be availableknowledgeable toof providersand inhave aexperience singleproviding locationthe onsame or similar service as the managedhealth care organization'sservice website.under review, and must have authority to modify or overturn the care determination decision.

The(2) notificationManaged mustcare beorganizations providedmaintain independentthe ofability otherto policymake changesadjustments orto providerpolicies notification publications and beprocedures easilythat accessibleimpact inthe electronicapplicability providerof andtheir enrolleeprior portals.authorization requirements.

(b)Beginning AdjustmentsAugust to1, policies2025, andthese proceduresadjustments thatcan impactonly the applicability of prior authorization requirements to reflect federal food and drug administration approvals, national comprehensive cancer network guidelines, United States preventive services task force guidelines, or state or national public health emergencies may be made atonce anyannually time and shallgo beinto postedeffect onJanuary the1st websiteof referencedany ingiven (a)calendar ofyear. this subsection.

Notification of adjustmentspolicy madechanges under this subsection must be provided to all in-network providers asat soonleast asfour possible.months prior to the January 1st effective date.

p.The notification must be provided independent to other policy changes or provider notification publications and be easily accessible in electronic provider and enrollee portals.

11(3)(a) SHBA 1566determination (3)(a)of Onlymedical necessity shall be made only by a licensed physician or a licensed health professional working within their scope of practicepractice. may deny a prior authorization request based on medical necessity.

An artificial intelligenceintelligence, toolp. shall not be the sole means used to deny, delay, or modify health care services.

Algorithms11 mayHB be1566 usedalgorithm, toor processrelated andsoftware approvetool priorshall authorization requests, but may not be usedthe withoutsole humanmeans reviewused to denydeny, caredelay, basedor onmodify ahealth determinationcare ofservices. medical necessity.

(b) A managed care organization and any contracted health care benefit manager that uses an artificial intelligenceintelligence, algorithm, or other software tool for the purpose of prior authorization or prior authorization functions, based in whole or in part on medical necessity, or that contracts with or otherwise works through an entity that uses an artificial intelligenceintelligence, algorithm, or related software tool for the purpose of prior authorization or prior authorization functions, based in whole or in part on medical necessity, shall ensure all of the following:

(i) The artificial intelligenceintelligence, algorithm, or other software tool bases its determination on the following information, as applicable:

(A) An enrollee's medical or other clinical history,history; including demographic data;

and (B) Individual clinical circumstances as presented by the requesting provider;

(ii)and The(C) artificialOther intelligencerelevant toolclinical doesinformation notcontained basein itsthe determinationenrollee's solelymedical onor aother groupclinical datarecord; set;

(iii)(ii) The artificial intelligenceintelligence, tool'salgorithm, criteriaor andother guidelinessoftware complytool withdoes thisnot chapterbase andits applicabledetermination statesolely andon federala law;group data set;

(iv)(iii) The use of the artificial intelligenceintelligence, toolalgorithm, doesor notother discriminate,software directlytool's orcriteria indirectly,and againstguidelines ancomplies enrolleewith inthis violationchapter ofand applicable state orand federal law;

(v)(iv) The artificialuse intelligenceof toolthe isartificial fairlyintelligence, andalgorithm, equitablyor applied,other includingsoftware intool accordancedoes withnot anydiscriminate, applicabledirectly regulationsor andindirectly, guidanceagainst issuedan byenrollee thein federalviolation department of healthstate andor humanfederal services;law;

(vi)(v) The policiesartificial intelligence, algorithm, or other software tool is fairly and proceduresequitably forapplied, usingincluding thein artificialaccordance intelligencewith toolany areapplicable openregulations toand auditguidance issued by the authorityfederal consistentdepartment withof RCWhealth 74.09.200;and human services;

p.(vi) The policies and procedures for using the artificial intelligence, algorithm, or other software tool is open to audit by the authority consistent with RCW 74.09.200;

12 SHB 1566 (vii) The artificial intelligenceintelligence, algorithm, or other software tool's performance, use, and outcomes are periodically reviewed by the managed care organization to maximize accuracy and reliability;

and (viii) Patient data is not used beyond its intended and stated purpose, consistent with chapter 70.02 RCW and the federal health insurancep. portability and accountability act of 1996, 42 U.S.C.

12 HB 1566 insurance portability and accountability act of 1996, 42 U.S.C.

(4)(4)(a) By JulyJanuary 1, 2027,2026, themanaged authoritycare organizations shall publishsubmit athe listtotal number of treatments, prescription drugs, equipment, and services, along with their applicable billing codes, that specifies under which circumstances prior authorization isrequests, required,approvals, prohibited,and ordenials hasto other uniform application across the medicalauthority assistanceon programa underquarterly thisbasis. chapter.

TheManaged authoritycare mustorganizations considershall applicablereport statethese totals by health plan and federalfor lawseach whenhealth decidingcare whichbenefit servicesmanager arethat notis subjectdelegated to priorprovide authorization.care determinations on behalf of the managed care organization.

TheManaged authoritycare organizations shall focusindicate onthe existingpercentage priorof authorizationtotal requirementsdenials andthat treatments,were prescriptionaided drugs,by equipment,artificial intelligence tools and servicesalgorithms thatand arethe treatedpercent inconsistentlyof incare determinations made after the medicalemergent assistanceand program.nonemergent authorization request turnaround times stated above.

(b) The authority shall updateprovide thea listreporting attemplate leastto annuallymanaged andcare provideorganizations notice90 anddays anprior opportunityto forthe publicfirst commentreport priorsubmission toand finalizingshall review the list.template annually for updates.

Nothing(c) inThe thisauthority subsectionshall alterspublish existingon obligationsits ofwebsite the authorityresults andof each managed care organizationsorganization's toreport ensure45 enrolleedays accessafter tosubmission, treatments,along prescriptionwith drugs,their equipment,own andprior servicesauthorization thatstatistics arefor notfee-for- includedservice inmedicaid theenrollees. list.

Nothing(5) inBy thisJuly section1, prohibits2027, the authority andshall manageddetermine carewhich organizationstreatments, fromprescription applyingdrugs, otherand utilizationservices, managementalong strategies, consistent with statetheir andapplicable federalbilling law,codes, fordo servicesnot forrequire which prior authorization isby notmanaged required.care organizations for any medicaid enrollee.

(5)(a)The Eachauthority managedmust careconsider organizationapplicable shallstate build and maintainfederal aprogram priorintegrity authorizationregulations applicationwhen programmingdeciding interfacewhich thatservices automatesthey thewill processwaive for in-network providers to determine whether a prior authorization isrequirements. required for health care services, identify prior authorization information and documentation requirements, and facilitate the exchange of prior authorization requests and determinations from its electronic health records or practice management system.

(6)(a) Each managed care organization shall build and maintain a prior authorization application programming interface that automates the process for in-network providers to determine whether a prior authorization is required for health care services, identify prior authorization information and documentation requirements, and facilitate the exchange of prior authorization requests and determinations from its electronic health records or practice management system.

13 SHBHB 1566 (ii) Automate the process to determine whether a prior authorization is required for durable medical equipment or a health care service;

and (iv) Include thea credentials,unique boardidentifier certifications,for andthe areasindividual ofwho specialtyinitially expertisereviewed and trainingmade of the providerdetermination. who had clinical p.

14The SHB 1566 oversight over the determination in any notification sent to the managed care enrolleeorganization andp. provider requesting or referring the service.

14 HB 1566 and any contracted health care benefit manager must also include the national provider identification number of the physician who had clinical oversight for the determination as well as the physician's credentials, board certifications, and areas of specialty expertise and training in any notification sent to the managed care enrollee and provider requesting or referring the service.

(ii) The authority may grant a one-year delay in enforcement of the requirements of (a) of this subsection (((2))) (5)(6) if the authority determines that the managed care organization has made a good faith effort to comply with the requirements.

(iii) This subsection (((2))) (5)(d)(6)(d) shall not apply if the delay in enforcement in (c) of this subsection takes effect because the federal centers for medicare and medicaid services did not finalize the applicable regulations by September 13, 2023.

(((3))) (6)(7) ThisNothing in this section applies to prior authorization functionsdeterminations carriedmade outpursuant byto health care benefit managers, as defined in RCW 48.200.020,71.24.618 under direct or indirect74.09.490. contract with a carrier.

(7)(((4))) The(8) authorityFor maythe adoptpurposes anyof rules necessary to implement this section.section:

(8) Nothing in this section applies to prior authorization determinations made pursuant to RCW 71.24.618 or 74.09.490.

(((4))) (9) For the purposes of this section:

15 SHBHB 1566 computer vision, speech or natural language processing, content generation, and contentforecasting generation.future outcomes.

"Artificial intelligence" includes generative artificial intelligence.

(((b))) (c) "Generative"Standard artificialprior intelligence"authorization request" means ana artificialrequest intelligenceby systema thatprovider generatesor novelfacility datafor approval of a health care service or contentprescription baseddrug onwhere the request is made in advance of the enrollee obtaining a foundationhealth model.care service or prescription drug that is not required to be expedited.

(d) "Machine learning" means the process by which artificial intelligence is developed using data and algorithms to draw inferences therefrom to automatically adapt or improve its accuracy without explicit programming.

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

(a) The health plan shall meet the following time frames for prior authorization determinations and notifications to a participating provider or facility that submits the prior p.authorization request through an electronic prior authorization process:

16 SHB 1566 authorization request through an electronic prior authorization process:

If insufficient information has been providedp. 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.

16 HB 1566 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.

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

17 SHB 1566 facility of the results of the decision within two calendar days of submission of a nonelectronic prior authorization request by the provider or facility that contains the necessary information to make a determination.

(c)p. 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.

17 HB 1566 (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.

(((2))) (e) When denyingissuing a notification for a prior authorization determination, the health plan shalland includeany thecontracted credentials,health boardcare certifications,benefit andmanager areasshall ofinclude specialtya expertiseunique andidentifier trainingfor of the providerindividual who hadinitially clinicalreviewed oversight over the determination in any notification sent to the health plan enrollee and providermade requesting or referring the service.determination.

(2)(a)The Healthhealth plansplan maintainshall also include the abilitynational toprovider makeidentification adjustmentsnumber toof policiesthe andphysician procedureswho thathad impactclinical oversight for the applicabilitydetermination as well as the physician's credentials, board certifications, and areas of theirspecialty priorexpertise authorizationand requirements.training in any notification sent to the health plan enrollee and provider requesting or referring the service.

Except(f) asIn providedthe incase (b) of thisan subsection,adverse beginningbenefit Augustdetermination, 1,a 2025,health theseplan adjustmentsshall canmake onlyavailable beto madethe quarterlyrequesting andprovider goa intopeer-to-peer effectreview eitherdiscussion. January 1st, April 1st, July 1st, or October 1st of any given calendar year.

NotificationThe peer reviewer provided by the health plan must possess a current and valid nonrestricted license to practice medicine in Washington state and must be knowledgeable of p.and have experience providing the same or similar service as the health care service under review, and must have authority to modify or overturn the care determination decision.

18(2) SHBHealth 1566plans policymaintain changesthe mustability be provided to allmake in-networkadjustments providers at least 45 days prior to thepolicies quarterly update and mustprocedures bethat availableimpact tothe providersapplicability inof atheir singleprior locationp. on the health plan's website.

The18 notificationHB must1566 beauthorization providedrequirements. independent of other policy changes or provider notification publications and be easily accessible in electronic provider and enrollee portals.

(b)Beginning AdjustmentsAugust to1, policies2025, andthese proceduresadjustments thatcan impactonly the applicability of prior authorization requirements to reflect federal food and drug administration approvals, national comprehensive cancer network guidelines, United States preventive services task force guidelines, or state or national public health emergencies may be made atonce anyannually time and shallgo beinto postedeffect onJanuary the1st websiteof referencedany ingiven (a)calendar ofyear. this subsection.

Notification of adjustmentspolicy madechanges under this subsection must be provided to all in-network providers asat soonleast asfour possible.months prior to the January 1st effective date.

(3)(a)The Onlynotification amust licensedbe physicianprovided orindependent ato licensedother healthpolicy professionalchanges workingor withinprovider theirnotification scopepublications ofand practicebe mayeasily denyaccessible ain priorelectronic authorizationprovider requestand basedenrollee onportals. medical necessity.

(3)(a) A determination of medical necessity shall be made only by a licensed physician or a licensed health professional working within their scope of practice.

An artificial intelligenceintelligence, algorithm, or related software tool shall not be the sole means used to deny, delay, or modify health care services.

Algorithms(b) mayA behealth usedplan toand processany andcontracted approvehealth care benefit manager that uses an artificial intelligence, algorithm, or other software tool for the purpose of prior authorization requests,or butprior mayauthorization notfunctions, bebased usedin withoutwhole humanor reviewin topart denyon caremedical necessity, or that contracts with or otherwise works through an entity that uses an artificial intelligence, algorithm, or related software tool for the purpose of prior authorization or prior authorization functions, based in whole or in part on amedical determinationnecessity, shall ensure all of medicalthe necessity.following:

(b)(i) AThe health plan that uses an artificial intelligenceintelligence, toolalgorithm, for the purpose of prior authorization or priorother authorizationsoftware functions,tool basedbases inits wholedetermination or in part on medical necessity, or that contracts with or otherwise works through an entity that uses an artificial intelligence tool for the purposefollowing ofinformation, prioras authorizationapplicable: or prior authorization functions, based in whole or in part on medical necessity, shall ensure all of the following:

(i)(A) TheAn artificialenrollee's intelligencemedical toolor basesother itsclinical determinationhistory; on the following information, as applicable:

(A)(B) AnIndividual enrollee'sclinical medicalcircumstances oras otherpresented clinicalby history,the includingrequesting demographicprovider; data;

and p.(C) Other relevant clinical information contained in the enrollee's medical or other clinical record;

19(ii) SHBThe 1566artificial (B)intelligence, Individualalgorithm, clinicalor circumstancesother assoftware presentedtool bydoes thenot requestingbase provider;its determination solely on a group data set;

(ii)(iii) The artificial intelligenceintelligence, toolalgorithm, doesor notother basesoftware itstool's determinationcriteria solelyand onguidelines acomplies groupwith datathis set;chapter and applicable state and federal law;

(iii)p. The artificial intelligence tool's criteria and guidelines comply with this chapter and applicable state and federal law;

19 HB 1566 (iv) The use of the artificial intelligenceintelligence, algorithm, or other software tool does not discriminate, directly or indirectly, against an enrollee in violation of state or federal law;

(v) The artificial intelligenceintelligence, algorithm, or other software tool is fairly and equitably applied, including in accordance with any applicable regulations and guidance issued by the federal department of health and human services;

(vi) The policies and procedures for using the artificial intelligenceintelligence, algorithm, or other software tool is open to audit by the office of the insurance commissioner;

(vii) The artificial intelligenceintelligence, algorithm, or other software tool's performance, use, and outcomes are periodically reviewed by the health plan to maximize accuracy and reliability;

p.(iii) Allow providers to query the health plan's prior authorization documentation requirements;

20(iv) SHBSupport 1566an (iii)automated Allowapproach providersusing nonproprietary open workflows to querycompile and exchange the healthnecessary plan'sdata elements to populate the prior authorization documentationrequirements requirements;that are compliant with the federal health insurance portability and accountability act of p.

(iv)20 SupportHB an1566 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;

and (vi) Include thea credentials,unique boardidentifier certifications,for and areas of specialty expertise and training of the providerindividual who hadinitially clinicalreviewed oversight over the determination in any notification sent to the health plan enrollee and providermade requesting or referring the service.determination.

The health plan and any contracted health care benefit manager must also include the national provider identification number of the physician who had clinical oversight for the determination as well as the physician's credentials, board certifications, and areas of specialty expertise and training in any notification sent to the health plan enrollee and provider requesting or referring the service.

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 p.subject to the health plan's grievance and appeal process under RCW 48.43.535.

21(c) SHBIf 1566federal subjectrules related to thestandards healthfor plan'susing grievancean andapplication appealprogramming processinterface underto RCWcommunicate 48.43.535.prior authorization p.

(c)21 IfHB federal1566 rules related 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 may not be enforced until January 1, 2026.

(((4))) (6) ThisFor sectionthe appliespurposes toof priorthis authorizationsection: functions carried out by health care benefit managers, as defined in RCW 48.200.020, under direct or indirect contract with a carrier.

(7)(a) The"Artificial commissionerintelligence" maymeans adoptthe anyuse rulesof necessarymachine learning and related technologies that use data to implementtrain thisstatistical section.models for the purpose of enabling computer systems to perform tasks normally associated with human intelligence or perception, such as computer vision, speech or natural language processing, content generation, and forecasting future outcomes.

(8) For the purposes of this section:

(a) "Artificial intelligence" means the use of machine learning and related technologies that use data to train statistical models for the purpose of enabling computer systems to perform tasks normally associated with human intelligence or perception, such as computer vision, speech or natural language processing, and content p.

22 SHB 1566 generation.

"Artificial intelligence" includes generative artificial intelligence.

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;

22 HB 1566 (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))) (c) "Generative"Standard artificialprior intelligence"authorization request" means ana artificialrequest intelligenceby systema thatprovider generatesor novelfacility datafor approval of a health care service or contentprescription baseddrug onwhere the request is made in advance of the enrollee obtaining a foundationhealth model.care service that is not required to be expedited.

(d)(((5))) "Machine(7) learning"This meanssection theshall processnot byapply whichto artificialcoverage intelligenceprovided isunder developedthe usingmedicare datapart andC algorithmsor topart drawD inferencesprograms therefromset toforth automaticallyin adaptTitle orXVIII improveof itsthe accuracysocial withoutsecurity explicitact programming.of 1965, as amended.

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

(((5))) (9) This section shall not apply to coverage provided under the medicare part C or part D programs set forth in Title XVIII of the social security act of 1965, as amended.

(1) A health carrier that offers a health plan shall not retrospectively deny coverage or retrospectively modify to a service less intensive than that included in the original request for emergency and nonemergency care that had prior authorization,authorization including for medical necessity, under the plan's written policies at the time the care was rendered,rendered. unless:

p.(2) Retrospective denials shall not be considered adverse benefit determinations and will not be required to follow the standard appeals processes in RCW 48.43.525 or any carrier policies related to their own grievance and appeals process.

23 SHB 1566 (a) The prior authorization was based upon a material misrepresentation by the provider, facility, or covered person;

or (b) The underlying health plan coverage is lawfully rescinded, canceled, or terminated retrospectively through the date of service.

(2) Retrospective denials of services with prior authorization or retrospective modification to less intensive services due to a change in the carrier's determination of medical necessity are prohibited, shall not be considered adverse benefit determinations, and will not be required to follow the standard appeals processes in RCW 48.43.530 or any carrier policies related to their own grievance and appeals process.

Interest will be assessed on the associated claim submitted by the provider at the rate of one percent per month, retroactive to the original date of the authorization request.

(1) By ((October 1, 2020,)) January 1, 2026, and annually thereafter, for individual and group health plans issued by a carrier thatp. has written at least one percent of the total accident and health insurance premiums written by all companies authorized to offer accident and health insurance in Washington in the most recently available year, the carrier shall report to the commissioner the following aggregated and deidentified data related to the carrier's prior authorization practices and experience for the prior plan year:

23 HB 1566 that has written at least one percent of the total accident and health insurance premiums written by all companies authorized to offer accident and health insurance in Washington in the most recently available year, the carrier shall report to the commissioner the following aggregated and deidentified data related to the carrier's prior authorization practices and experience for the prior plan ((year)) quarter:

The carrier must report these totals separately for approvals or denials made by theboth carrierhealth directlyplan and foreach approvals or denials made by a health care benefit manager as defined in RCW 48.200.020 that is delegated to makeprovide priorcare authorizationdeterminations determinations, either directly or indirectly, on behalf of the carrier.

p.(i) The percentage of total denials that were aided by artificial intelligence tools and algorithms;

24and SHB(ii) 1566 (i) The percentagepercent of totalcare denialsdeterminations thatmade wereafter aidedthe byemergent artificialand intelligencenonemergent tools;authorization request turnaround times stated in RCW 48.43.830;

and (ii) The percent of prior authorization determinations made after the standard and expedited authorization request turnaround times stated in RCW 48.43.830;

and (iii)p. With the highest percentage of prior authorization requests that were initially denied and then subsequently approved on appeal, including the total number of prior authorization requests for each code and the percent of requests that were initially denied and then subsequently approved for each code;

24 HB 1566 (iii) With the highest percentage of prior authorization requests that were initially denied and then subsequently approved on appeal, including the total number of prior authorization requests for each code and the percent of requests that were initially denied and then subsequently approved for each code;

p.(ii) With the highest percentage of approved prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code;

25 SHB 1566 (ii) With the highest percentage of approved prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code;

(ii)p. With the highest percentage of approved prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code;

25 HB 1566 (ii) With the highest percentage of approved prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code;

p.(i) With the highest total number of prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code;

26 SHB 1566 (i) With the highest total number of prior authorization requests during the previous plan year, including the total number of prior authorization requests for each code and the percent of approved requests for each code;

and (((h))) (i) The average determination response time in hours for prior authorization requests to the carrier in total reported under (a)p. of this subsection and with respect to each code reported under (((a))) (b) through (((f))) (h) of this subsection for each of the following categories of prior authorization:

26 HB 1566 (a) of this subsection and with respect to each code reported under (((a))) (b) through (((f))) (h) of this subsection for each of the following categories of prior authorization:

p.(b) The report must contain trend data for total authorization requests, approvals, and denials by plan and health care benefit managers.

27 SHB 1566 (b) The report must contain trend data for total authorization requests, approvals, and denials by plan and health care benefit managers.

2827 SHBHB 1566