SB 5395 — Making improvements to transparency and accountability in the prior authorization determination process.

(((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 generation.

"Artificial intelligence" includes generative artificial intelligence.

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

8 SSB 5395 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 athe foundationrequest model.is made in advance of p.

(d)8 "MachineSB learning"5395 means the processenrollee byobtaining whicha artificialhealth intelligencecare isservice developedor usingprescription datadrug andthat algorithmsis tonot drawrequired inferences therefrom to automaticallybe adaptexpedited. 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.

p.(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 information to make a determination.

9 SSB 5395 (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 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))) (6) of this section:

9 SB 5395 prior authorization process described in subsection (((2))) (6) of this section:

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

10 SSB 5395 reasonable time frame for submission of the additional information.

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 SB 5395 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 new application of prior authorization for health care servicesorganization orshall prescriptionmake drugsavailable canto onlythe berequesting madeprovider quarterlya andpeer-to-peer goreview intodiscussion. effect either January 1st, April 1st, July 1st, or October 1st of any given calendar year.

NotificationThe ofpeer policyreviewer changesprovided by the managed care organization must bepossess provideda current and valid nonrestricted license to allpractice in-networkmedicine providersin onWashington state and must be knowledgeable of and have experience providing the electronicsame prioror authorizationsimilar systemservice as the health care service under review, and must have authority to modify or applicationoverturn programmingthe interfacecare system.determination decision.

Until(2) JanuaryManaged 1,care 2028,organizations thismaintain informationthe mustability alsoto bemake providedadjustments at least 45 days prior to thepolicies quarterly update and mustprocedures bethat availableimpact tothe providersapplicability inof atheir singleprior locationauthorization onrequirements. the managed care organization's website.

TheBeginning notificationAugust must1, be2025, providedthese independentadjustments ofcan otheronly policybe changesmade oronce providerannually notification publications and bego easilyinto accessibleeffect inJanuary electronic1st providerof andany enrolleegiven portals.calendar year.

p.Notification of policy changes must be provided to all in-network providers at least four months prior to the January 1st effective date.

11The SSBnotification 5395must (b)be Adjustmentsprovided toindependent policies and procedures that impact the applicability of prior authorization requirements to reflectother newpolicy evidencechanges for health care services or prescriptionprovider drugsnotification includingpublications nationallyand recognizedbe standardseasily ofaccessible carein thatelectronic are publicly available, consensus guidelines of nonprofit health care provider professional associations, nationally recognized clinical practice guidelines that are publicly available, guidelines or recommendations of federal government agencies including federal food and drugenrollee administrationportals. approvals, or state or national public health emergencies may be made at any time.

Notification(3)(a) ofA adjustmentsdetermination madeof undermedical thisnecessity subsectionshall must be providedmade toonly allby in-networka providerslicensed asphysician soonor asa possiblelicensed andhealth mustprofessional beworking availablewithin totheir providersscope onof thepractice. electronic prior authorization system or application programming interface system.

Until January 1, 2028, this information must also be provided in a single location on the managed care organization's website referenced in (a) of this subsection.

Managed care organizations may remove prior authorization requirements at any time.

(3)(a) Only a licensed physician or a licensed health professional working within their scope of practice may deny a prior authorization request based on medical necessity.

ArtificialAn intelligenceartificial shallintelligence, notp. be the sole means used to deny, delay, or modify health care services.

Algorithms11 maySB be5395 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:

p.(A) An enrollee's medical or other clinical history;

12(B) SSBIndividual 5395clinical (A)circumstances Anas enrollee'spresented medicalby orthe otherrequesting clinicalprovider; history, including demographic data;

and (B)(C) IndividualOther relevant clinical circumstancesinformation ascontained presentedin by the requestingenrollee's provider;medical or other clinical record;

(ii) The artificial intelligenceintelligence, algorithm, or other software tool does not base its determination solely on a group data set;

(iii) The artificial intelligence'sintelligence, algorithm, or other software tool's criteria and guidelines complycomplies with this chapter and applicable state and federal law;

(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, arealgorithm, or other software tool is open to audit by the authority consistent with RCW 74.09.200;

(vii) The artificial intelligence'sintelligence, 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 SB 5395 insurance portability and accountability act of 1996, 42 U.S.C.

Managed care organizations shall indicate the percentage of total denials that were aided by artificial intelligence tools and algorithms and the percent of care determinations made after the emergent and nonemergent authorization request turnaround times listedstated inabove. subsection (1) of this section.

(c) The authority shall publish on its website the results of each managed care organization's report 45 days after submission, p.along with their own prior authorization statistics for fee-for- service medicaid enrollees.

13(5) SSBBy 5395July 1, 2027, the authority shall determine which treatments, prescription drugs, and services, along with their ownapplicable billing codes, do not require prior authorization statisticsby formanaged fee-for-care serviceorganizations for any medicaid enrollees.enrollee.

(5)The By July 1, 2027, the authority shallmust publishconsider aapplicable liststate of treatments, prescription drugs, equipment, and services,federal alongprogram withintegrity theirregulations applicablewhen billingdeciding codes,which thatservices specifiesthey underwill whichwaive circumstances prior authorization isrequirements. required, prohibited, or has other uniform application across the medical assistance program under this chapter.

The authority must consider applicable state and federal laws when deciding which services are not subject to prior authorization.

The authority shall focus on existing prior authorization requirements and treatments, prescription drugs, equipment, and services that are treated inconsistently in the medical assistance program.

The authority shall update the list at least annually and provide notice and an opportunity for public comment prior to finalizing the list.

Nothing in this subsection alters existing obligations of the authority and managed care organizations to ensure enrollee access to treatments, prescription drugs, equipment, and services that are not included in the list.

Nothing in this section prohibits the authority and managed care organizations from applying other utilization management strategies, consistent with state and federal law, for services for which prior authorization is not required.

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

(iii) Allow providers to query the managed care organization's prior authorization documentation requirements;

1413 SSBSB 5395 (iv)(ii) SupportAutomate an automated approach using nonproprietary open workflows to compile and exchange the necessaryprocess data elements to populatedetermine thewhether a prior authorization requirementsis thatrequired arefor compliantdurable withmedical theequipment federal health insurance portability and accountability act of 1996 or havea anhealth exceptioncare fromservice; the federal centers for medicare and medicaid services;

(iii) Allow providers to query the managed care organization's prior authorization documentation requirements;

(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;

and((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 subject to the managed care organization's grievance and appeal process under RCW 48.43.535.48.43.535;

and (iv) Include a unique identifier for the individual who initially reviewed and made the determination.

The managed care organization p.

14 SB 5395 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.

(d)(i) If a managed care organization determines that it will not be able to satisfy the requirements of (a) of this subsection by p.January 1, 2025, the managed care organization shall submit a narrative justification to the authority on or before September 1, 2024, describing:

15 SSB 5395 January 1, 2025, the managed care organization shall submit a narrative justification to the authority on or before September 1, 2024, describing:

(((3))) (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.

(((4))) (8) TheFor authoritythe maypurposes adoptof any rules necessary to implement this section.section:

(9)(a) Nothing"Artificial inintelligence" thismeans sectionthe appliesuse of machine learning and related technologies that use data to priortrain authorizationstatistical determinationsmodels madefor pursuantthe purpose of enabling computer systems to RCWperform 71.24.618tasks normally associated with human intelligence or 74.09.490.perception, such as p.

(((4)))15 (10)SB For5395 thecomputer purposesvision, ofspeech thisor section:natural language processing, content generation, and forecasting future outcomes.

(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.

p.(B) Could seriously jeopardize the enrollee's ability to regain maximum function;

16 SSB 5395 (B) Could seriously jeopardize the enrollee's ability to regain maximum function;

(((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.

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

1716 SSBSB 5395 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.

1817 SSBSB 5395 (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, new application of prior authorization for health careplan servicesshall ormake prescriptionavailable drugsto canthe onlyrequesting beprovider madea quarterlypeer-to-peer andreview godiscussion. into effect either January 1st, April 1st, July 1st, or October 1st of any given calendar year.

NotificationThe ofpeer policyreviewer changesprovided mustby bethe providedhealth toplan allmust in-networkpossess providersa atcurrent leastand 45valid daysnonrestricted priorlicense to thepractice quarterlymedicine updatein Washington state and must be availableknowledgeable toof providersand onhave experience providing the electronicsame prioror authorizationsimilar systemservice as the health care service under review, and must have authority to modify or applicationoverturn programmingthe interfacecare system.determination decision.

Until(2) JanuaryHealth 1,plans 2028,maintain thisthe informationability mustto alsomake beadjustments providedto inpolicies aand singleprocedures locationthat onimpact the healthapplicability plan'sof website.their prior p.

The18 notificationSB must5395 beauthorization providedrequirements. independent of other p.

19Beginning SSBAugust 53951, policy2025, changesthese oradjustments providercan notificationonly publicationsbe made once annually and bego easilyinto accessibleeffect inJanuary electronic1st providerof andany enrolleegiven portals.calendar year.

(b)Notification Adjustmentsof topolicy policieschanges andmust proceduresbe thatprovided impact the applicability of prior authorization requirements to reflectall newin-network evidenceproviders forat healthleast carefour servicesmonths orprior prescriptionto drugsthe includingJanuary nationally1st recognizedeffective standardsdate. of care that are publicly available, consensus guidelines of nonprofit health care provider professional associations, nationally recognized clinical practice guidelines that are publicly available, guidelines or recommendations of federal government agencies including federal food and drug administration approvals, or state or national public health emergencies may be made at any time.

NotificationThe ofnotification adjustments made under this subsection must be provided independent to allother in-networkpolicy providerschanges asor soonprovider asnotification possiblepublications and must be availableeasily toaccessible providersin on the electronic priorprovider authorizationand systemenrollee orportals. application programming interface system.

Until(3)(a) JanuaryA 1,determination 2028,of thismedical informationnecessity mustshall also be providedmade inonly by a singlelicensed locationphysician onor thea licensed health plan'sprofessional websiteworking referencedwithin intheir (a)scope of thispractice. subsection.

Health plans may remove prior authorization requirements at any time.

(3)(a) Only a licensed physician or a licensed health professional working within their scope of practice may deny a prior authorization request based on medical necessity.

ArtificialAn intelligenceartificial intelligence, 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 artificial intelligenceintelligence, foralgorithm, 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 artificial intelligence 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 basesor itsother determinationclinical onhistory; the following information, as applicable:

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

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

(ii) The artificial intelligence, algorithm, or other software tool does not base its determination solely on a group data set;

(iii) The artificial intelligence, algorithm, or other software tool's criteria and guidelines complies with this chapter and applicable state and federal law;

2019 SSBSB 5395 (A)(iv) AnThe enrollee'suse medicalof the artificial intelligence, algorithm, or other clinicalsoftware history,tool includingdoes demographicnot data;discriminate, directly or indirectly, against an enrollee in violation of state or federal law;

(v) The artificial intelligence, algorithm, or other software tool is fairly and (B)equitably Individualapplied, clinicalincluding circumstancesin asaccordance presentedwith any applicable regulations and guidance issued by the requestingfederal provider;department of health and human services;

(ii)(vi) The policies and procedures for using the artificial intelligenceintelligence, doesalgorithm, notor baseother itssoftware determinationtool solelyis onopen ato groupaudit databy set;the office of the insurance commissioner;

(iii)(vii) The artificial intelligence'sintelligence, criteriaalgorithm, andor guidelinesother complysoftware withtool's thisperformance, chapteruse, and applicableoutcomes stateare andperiodically federalreviewed law;to maximize accuracy and reliability;

(iv) The use of the artificial intelligence does not discriminate, directly or indirectly, against an enrollee in violation of state or federal law;

(v) The artificial intelligence 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 intelligence is open to audit by the office of the insurance commissioner;

(vii) The artificial intelligence's performance, use, and outcomes are periodically reviewed by the health plan to maximize accuracy and reliability;

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

21 SSB 5395 (ii) Automate the process to determine whether a prior authorization is required for durable medical equipment or a health care service;

(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 1996p. or have an exception from the federal centers for medicare and medicaid services;

and20 (v)SB Indicate5395 that1996 a prior authorization denial or authorizationhave ofan aexception servicefrom less intensive than that included in the originalfederal requestcenters isfor anmedicare adverse benefit determination and ismedicaid subjectservices; to the health plan's grievance and appeal process under RCW 48.43.535.

((and)) (v) Indicate 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 health plan's grievance and appeal process under RCW 48.43.535;

and (vi) Include a unique identifier for the individual who initially reviewed and made the 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.

(c) If federal rules related to standards for using an application programming interface to communicate prior authorization p.

2221 SSBSB 5395 (c) If federal 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 authorityintelligence" 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)(b) For"Expedited theprior purposesauthorization request" means a request by a provider or facility for approval of thisa section:health care service or prescription drug where:

(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.

p.

23 SSB 5395 (b) "Expedited prior authorization request" means a request by a provider or facility for approval of a health care service or prescription drug where:

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 SB 5395 (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:

(a)(2) TheRetrospective priordenials authorizationshall wasnot basedbe uponconsidered aadverse materialbenefit misrepresentationdeterminations byand will not be required to follow the provider,standard facility,appeals processes in RCW 48.43.525 or coveredany person;carrier policies related to their own grievance and appeals process.

or p.

24 SSB 5395 (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 service.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 SB 5395 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 authorization determinations either directly or indirectly on behalf of the carrier.

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

p.and (ii) The percent of care determinations made after the emergent and nonemergent authorization request turnaround times stated in RCW 48.43.830;

25 SSB 5395 (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) The total number of nonelectronic standard and nonelectronic expedited prior authorization requests;

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 SB 5395 (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;

26 SSB 5395 (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 SB 5395 (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;

27 SSB 5395 (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 SB 5395 (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.

28 SSB 5395 (b) The report must contain trend data for total authorization requests, approvals, and denials by plan and health care benefit managers.

2927 SSBSB 5395