WHAT THIS BILL REGULATES · 4 REQUIREMENT TYPES
How Is This Bill Enforced
Verbatim statutory text on the left; plain-language analysis and a per-section checklist on the right. Numbered markers cross-link to the matching checklist row.
(1)–(3) The legislature finds that health carriers are the decision makers for the type and level of care covered for an enrollee's health care benefits and are not responsible for determining or altering an enrollee's diagnosis or treatment plan. It is not always transparent who the decision maker is or how decisions are made in determining enrollee coverage for treatment, prescription drugs, or services. Artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) is being increasingly utilized by health carriers to make or aid in decisions about medical necessity and coverage of provider-recommended treatment. (2) It is the intent of the legislature to increase transparency in the prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) process for health care coverage decisions and to ensure licensed physicians and licensed health professionals remain responsible for making determinations regarding treatments, prescription drugs, and other health care services. If artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) is used to aid in the decision-making process, standards must be put in place to ensure artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) is not used to make inappropriate determinations that could impact the health of an enrollee. (3) It is the intent of the legislature to update the protections of this act for enrollees to include managed care organizations as soon as feasible, recognizing that low-income, publicly insured Washingtonians deserve the same patient protections as higher-income, commercially insured Washingtonians.
Section 1 contains legislative findings and statements of intent. The legislature identifies health carriers as the decision makers for coverage determinations and expresses concern about increasing use of AI in medical necessity decisions. It declares an intent to increase transparency, ensure licensed physicians remain responsible for coverage determinations, establish standards for AI use, and eventually extend protections to managed care organization enrollees. No operative compliance obligations are created by this section.
(3)(a) 1 Only a licensed physician or a licensed health professional working within their scope of practice may deny a prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) request based on medical necessity. The licensed physician or licensed health professional shall evaluate the specific clinical issues involved in the health care services requested by the requesting provider by reviewing and considering the requesting provider's recommendation, the enrollee's medical or other clinical history, as applicable, and individual clinical circumstances. Artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) shall not be the sole means used to deny, delay, or modify health care services. Algorithms may be used to process and approve prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) requests, but may not be used without human review to deny care based on a determination of medical necessity.
(3)(b)(i)–(ii) 2 A carrier that uses artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) for the purpose of prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) or prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) functions, based in whole or in part on medical necessity, or that contracts with or otherwise works through an entity that uses artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) for the purpose of prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) or prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) functions, based in whole or in part on medical necessity, shall ensure all of the following: (i) The artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) bases its determination on the following information, as applicable: (A) An enrollee's medical or other clinical history, including demographic data; and (B) Individual clinical circumstances as presented by the requesting provider; (ii) The artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) does not base its determination solely on a group data set;
(3)(b)(iii)–(v) 3 The artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a)'s criteria and guidelines comply with this chapter and applicable state and federal law; (iv) The use of the artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) does not discriminate, directly or indirectly, against an enrollee in violation of state or federal law; (v) The artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) is fairly and equitably applied, including in accordance with any applicable regulations and guidance issued by the federal department of health and human services;
(3)(b)(vi) 4 The policies and procedures for using artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) are open to audit by the office of the insurance commissioner under chapter 48.37 RCW;
(3)(b)(vii) 5 The artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a)'s performance, use, and outcomes are periodically reviewed by the carrier to maximize accuracy and reliability;
(3)(b)(viii) 6 Patient data is not used beyond its intended and stated purpose, consistent with chapter 70.02 RCW and the federal health insurance portability and accountability act of 1996, 42 U.S.C. Sec. 1320d et al., as applicable.
(1)(e) 7 When denying a prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) determination, the carrier shall include the credentials, board certifications, and areas of specialty of the provider who had clinical oversight over the determination in any notification sent to the health plan enrollee and provider requesting or referring the service.
(2) 8 Carriers must post any adjustments to policies and procedures that impact the applicability of their prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) requirements for health care services or prescription drugs, including new applications of prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5), in a single location on the carrier's website. After December 30, 2030, any new application of prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) for health care services must be available to providers on the electronic prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) system or application programming interface system referenced in subsection (4) of this section.
(8) For the purposes of this section: (a) "Artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a)" means the use of machine learningMachine learning"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.RCW 48.43.830(8)(d) 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 intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a)" includes generative artificial intelligenceGenerative artificial intelligence"Generative artificial intelligence" means an artificial intelligence system that generates novel data or content based on a foundation model.RCW 48.43.830(8)(c). (b) "Expedited prior authorization requestExpedited prior authorization request"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: (A) Could seriously jeopardize the life or health of the enrollee; (B) Could seriously jeopardize the enrollee's ability to regain maximum function; or (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; or (ii) The enrollee is undergoing a current course of treatment using a nonformulary drug.RCW 48.43.830(8)(b)" means a request by a provider or facility for approval of a health care service or prescription drug where: (i) The passage of time: (A) Could seriously jeopardize the life or health of the enrollee; (B) Could seriously jeopardize the enrollee's ability to regain maximum function; or (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; or (ii) The enrollee is undergoing a current course of treatment using a nonformulary drug. (c) "Generative artificial intelligenceGenerative artificial intelligence"Generative artificial intelligence" means an artificial intelligence system that generates novel data or content based on a foundation model.RCW 48.43.830(8)(c)" means an artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) system that generates novel data or content based on a foundation model. (d) "Machine learningMachine learning"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.RCW 48.43.830(8)(d)" means the process by which artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) is developed using data and algorithms to draw inferences therefrom to automatically adapt or improve its accuracy without explicit programming. (e) "Standard prior authorization requestStandard prior authorization request"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.RCW 48.43.830(8)(e)" 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.
(5)–(7) Nothing in this section applies to prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) determinations made pursuant to RCW 48.43.761. (6) This section applies to prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) functions carried out by health care benefit managers, as defined in RCW 48.200.020, under direct or indirect contract with a carrier. (7) The commissioner may adopt any rules necessary to implement this section.
This section imposes the core AI-related obligations on health carriers. Subsection (3)(a) prohibits AI from being the sole means used to deny, delay, or modify health care services and requires that only a licensed physician or licensed health professional may deny a prior authorization request based on medical necessity, considering the requesting provider's recommendation and the enrollee's individual clinical circumstances. Subsection (3)(b) establishes eight enumerated requirements for carriers using AI in prior authorization, including that the AI must base determinations on individual enrollee clinical data, must not rely solely on group data sets, must comply with applicable law, must not discriminate, and must be periodically reviewed for accuracy.
Subsection (1)(e) requires carriers to include the credentials, board certifications, and specialty of the denying clinician in every denial notification. Subsection (2) requires carriers to post prior authorization policy changes, including new applications of prior authorization, in a single location on their website; after December 30, 2030, new applications must be available via the electronic prior authorization system or API.
(3)(a) 9 Only a licensed physician or a licensed health professional working within their scope of practice may deny a prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) request based on medical necessity. The licensed physician or licensed health professional shall evaluate the specific clinical issues involved in the health care services requested by the requesting provider by reviewing and considering the requesting provider's recommendation, the enrollee's medical or other clinical history, as applicable, and individual clinical circumstances. Artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) shall not be the sole means used to deny, delay, or modify health care services. Algorithms may be used to process and approve prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) requests, but may not be used without human review to deny care based on a determination of medical necessity.
(3)(b) 10 A health plan that uses artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) for the purpose of prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) or prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) functions, based in whole or in part on medical necessity, or that contracts with or otherwise works through an entity that uses artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) for the purpose of prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) or prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) functions, based in whole or in part on medical necessity, shall ensure all of the following: (i) The artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) bases its determination on the following information, as applicable: (A) An enrollee's medical or other clinical history, including demographic data; and (B) Individual clinical circumstances as presented by the requesting provider; (ii) The artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) does not base its determination solely on a group data set; (iii) The artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a)'s criteria and guidelines comply with this chapter and applicable state and federal law; (iv) The use of the artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) does not discriminate, directly or indirectly, against an enrollee in violation of state or federal law; (v) The artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) 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 intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a) is open to audit by the office of the insurance commissioner; (vii) The artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a)'s performance, use, and outcomes are periodically reviewed by the health plan 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 insurance portability and accountability act of 1996, U.S.C. Sec. 1320d et al., as applicable.
Section 4 mirrors the obligations of RCW 48.43.830 for health plans offered to public employees, retirees, and their covered dependents under the state employees' benefits program (RCW 41.05). The substantive AI requirements are identical: AI may not be the sole basis for denying, delaying, or modifying health care services; the AI must base determinations on individual clinical data; it must not discriminate; it must be periodically reviewed for accuracy; and patient data must not be used beyond its stated purpose. The Health Care Authority, rather than the OIC, has rulemaking and enforcement authority for this section.
(1)–(2) 11 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 an approved request for emergency and nonemergency care that had prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5), including for medical necessity, under the plan's written policies at the time the care was rendered, unless: (a) The approved prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) 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 an approved prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) or retrospective modification of an approved prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) 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. If an enrollee, or the provider requesting the authorization demonstrates the authorization was valid per the plan's written policies, then the carrier will deem the authorization approved and payable. Interest will be assessed on the associated claim submitted by the provider at the rate of one percent per month, retroactive to the date of submission. An enrollee, or provider on behalf of the enrollee, may seek review by an independent review organization under RCW 48.43.535 without the need to engage in, exhaust, or wait for any timelines related to the carrier's grievance process.
Section 5 prohibits health carriers from retrospectively denying coverage or modifying approved prior authorization to less intensive services after care has been rendered, except where the authorization was based on material misrepresentation or the underlying coverage was lawfully rescinded. Retrospective denials based on changed medical necessity determinations are categorically prohibited. This provision protects enrollees and providers from carriers that might use AI to re-evaluate and retract previously approved authorizations. If a retrospective denial occurs and the enrollee or provider demonstrates the authorization was valid, the carrier must deem it approved and payable, with 1% per month interest on the claim retroactive to submission. Enrollees may bypass the carrier grievance process and proceed directly to independent review.
(2) 12 An enrollee may seek review by a certified independent review organization of a carrier's decision to deny, modify, reduce, or terminate coverage of or payment for a health care service or of any adverse determination made by a carrier under RCW 48.49.020, 48.49.030, or sections 2799A-1 or 2799A-2 of the public health service act (42 U.S.C. Secs. 300gg-111 or 300gg-112) and implementing federal regulations in effect as of March 31, 2022, after exhausting the carrier's grievance process and receiving a decision that is unfavorable to the enrollee, or after the carrier has exceeded the timelines for grievances provided in RCW 48.43.530, without good cause and without reaching a decision. Any requirements that the enrollee must first engage in, exhaust, or wait for any timelines related to the carrier's grievance process do not apply to review sought pursuant to RCW 48.43.525.
Sections 6 and 7 amend Washington's independent review organization (IRO) statute to add a new bypass provision: enrollees seeking review of retrospective denials of prior-authorized services under RCW 48.43.525 need not engage in, exhaust, or wait for the carrier's grievance process before seeking IRO review. This strengthens the enforcement backstop for the anti-retrospective-denial provision. The remainder of the section preserves existing IRO procedures. Section 6 expires January 1, 2027, when Section 7 takes effect with parallel provisions incorporating additional mental health parity cross-references (RCW 48.43.766).
(1)(a) 13 The total number of prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) requests, approvals, and denials. The carrier must report these totals separately for approvals or denials made by the carrier directly and for approvals or denials made by a health care benefit manager as defined in RCW 48.200.020 that is delegated to make prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) determinations either directly or indirectly on behalf of the carrier. In the report, carriers must also indicate: (i) The percentage of total denials that were aided by artificial intelligenceArtificial intelligence"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.RCW 48.43.830(8)(a); (ii) The percent of prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) 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 requestsExpedited prior authorization request"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: (A) Could seriously jeopardize the life or health of the enrollee; (B) Could seriously jeopardize the enrollee's ability to regain maximum function; or (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; or (ii) The enrollee is undergoing a current course of treatment using a nonformulary drug.RCW 48.43.830(8)(b);
(2)(b) 13 The report must contain trend data for total authorization requests, approvals, and denials submitted under subsection (1)(a) of this section separately for each carrier directly and for each health care benefit manager, as defined in RCW 48.200.020, that is delegated to make prior authorizationPrior authorization"Prior authorization" means a mandatory process that a carrier or its designated or contracted representative requires a provider or facility to follow before a service is delivered, to determine if a service is a benefit and meets the requirements for medical necessity, clinical appropriateness, level of care, or effectiveness in relation to the applicable plan, including any term used by a carrier or its designated or contracted representative to describe this process.RCW 48.43.0161(5) determinations either directly or indirectly on behalf of the carrier.
Section 8 expands the annual prior authorization data reporting requirements for large carriers (those writing at least 1% of total accident and health premiums in Washington). The report, due by October 1, 2026 and annually thereafter, must now include three new data points: (1) the percentage of total denials that were aided by artificial intelligence, (2) the percentage of determinations made after the statutory turnaround deadlines, and (3) the total number of nonelectronic prior authorization requests. The existing code-level reporting categories (inpatient, outpatient, mental health, durable medical equipment, diabetes supplies, prescription drugs) are retained and renumbered. The commissioner must separately report trend data for carriers and their delegated health care benefit managers.
Sections 2 and 6 of this act expire January 1, 2027.
Section 9 provides that Sections 2 and 6 of the act expire on January 1, 2027. At that point, the parallel provisions in Sections 3 and 7 — which incorporate additional mental health parity cross-references to RCW 48.43.766 — take effect. The substantive AI obligations are identical in both versions.
Sections 3 and 7 of this act take effect January 1, 2027.
Section 10 provides that Sections 3 and 7 take effect January 1, 2027. These are the reenacted versions of RCW 48.43.830 and RCW 48.43.535 that incorporate cross-references to the mental health and substance use disorder parity requirements of RCW 48.43.766.