Washington Insurance Commissioner Mike Kreidler has released the proposed language for a prior authorization rule aimed at updating timelines for health care services and prescription drug approvals. The rule also clarifies which health insurance plans must comply with these standards (see US Health Insurance Market Trends: Rates, Price and Coverage).
Medicare is federal health insurance for people aged 65 and older, are under age 65 on Social Security Disability Income or diagnosed with certain diseases.
Mandated by a 2023 prior authorization modernization law, the rule aims to reduce delays in care and improve health outcomes.
According to the regulator, the proposal updates several sections of the Washington Administrative Code to align with the new law and clearly outlines the rights and responsibilities of health care entities and carriers (see TOP 100 Life & Health Insurance Companies in the U.S.).
The draft rule specifies time frames for drug utilization reviews. For urgent care review requests, insurers must complete the review within 48 hours. If more information is needed, the carrier has 24 hours to request details from the provider, who must respond within 48 hours. The insurer then has 48 hours to make a final decision.
For nonurgent care review requests, a decision must be made within five calendar days if enough information is available. If more details are required, the carrier has five days to request them, and the provider must respond within five days.
Washington Insurance Commissioner Mike Kreidler
The insurer then has four calendar days to issue a decision. Both types of requests require the carrier to notify the provider and policyholder.
Standard health care service requests submitted electronically must be processed within three days after all required information is received.
If submitted nonelectronically, the response time is five calendar days. For urgent requests, electronic submissions have a one-day timeline, while nonelectronic submissions have a two-day window.
Approved prior authorizations will remain valid for at least 45 days. Efforts to get comments from America’s Health Insurance Plans and the insurance department were unsuccessful.
Commissioner Mike Kreidler has served the people of Washington in elected offices and appointed posts for more than 30 years. Born and raised around Tacoma, he has represented our state with dedication, while also managing a professional career in optometry.
Kreidler has distinguished himself through his work on health care and the environment to insurance. He was elected Washington State’s eighth Insurance Commissioner in November 2000. Voters returned him to office in 2004, 2008, 2012, 2016 and 2020.
