WashingtonWashington health plans require human review of care denials
Washington health plans must use licensed professionals to review medical-necessity denials, while electronic tools for prescription drug approvals begin January 1, 2027.
What it does
Licensed health professionals must review medical-necessity denials. Plans using artificial intelligence for prior authorization must follow safeguards for individual circumstances, fairness, audits, and patient data.
Health plans must let in-network providers check whether covered prescription drugs need approval and exchange requests and decisions electronically, including information about covered alternatives.
Carriers above a market-size threshold must report yearly data on prior authorization requests, decisions, and appeals, including whether AI helped with denials.
Argument forPatients could get decisions that better fit their circumstances because professionals must review medical-necessity denials and plans must check how AI is used.
Argument againstYearly reporting may take staff time from larger carriers as they track approval delays, appeal results, and whether AI helped with denials.
More detail
Licensed health professionals must review medical-necessity denials, and health plans using AI for prior authorization must follow safeguards. These rules cover health carriers and health plans for public employees, retirees, and their covered dependents. They also apply to contracted health care benefit managers. AI cannot be the only means used to deny, delay, or change care. Algorithms may approve requests, but a licensed professional must review medical-necessity denials. Plans using AI must consider the enrollee’s clinical history and individual circumstances, avoid decisions based only on group data, follow applicable law, and protect patient data. The rules in sections 3 and 7 take effect January 1, 2027.
Health plans must provide electronic tools for providers to check prescription drug approval requirements and exchange requests and decisions. These requirements cover in-network providers seeking approval for covered prescription drugs from carriers and public employee health plans. The tools must let in-network providers see required information and documents, and exchange requests and decisions through their electronic records or practice systems. A denial or approval of a different drug counts as an adverse benefit determination and is subject to the plan’s grievance and appeal process. The electronic exchange requirements begin January 1, 2027.
Certain large carriers must report prior authorization data to the insurance commissioner each year. Reports cover individual and group health plans from qualifying carriers and describe the prior plan year. The reporting duty applies to carriers that wrote at least one percent of Washington’s accident and health insurance premiums in the most recently available year. Carriers report grouped data that does not identify people. The commissioner must publish an aggregated report without naming the carriers. The first report is due October 1, 2026, with reports due annually after that.
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Where it stands
- Introduced
- Passed Senate
- Passed House
- To Governor
- Became Law
Looking ahead
No hearings or votes scheduled.
History
- 2026
- Mar 23Effective date 6/11/2026*.Latest
- Mar 23Chapter 157, 2026 Laws.Major
- Mar 23Governor Bob Ferguson signed.Became Law
- Mar 12Delivered to Governor.To Governor
- Mar 11Speaker signed.Major
- Mar 10President signed.Passed House
- Mar 9Passed final passage; yeas, 49; nays, 0; absent, 0; excused, 0.Passed Senate
- Vote recorded Final Passage as Amended by the House (#15). Result: pass.Upper
- Mar 9Senate concurred in House amendments.
- Mar 4Third reading, passed; yeas, 94; nays, 0; absent, 0; excused, 4.Minor
- Vote recorded Final Passage as Amended by the House (#24). Result: pass.Lower
- Mar 4Rules suspended. Placed on Third Reading.Minor
- Mar 4Committee amendment(s) adopted with no other amendments.
- Mar 4Rules Committee relieved of further consideration. Placed on second reading.Minor
- Mar 2Referred to Rules 2 Review.Minor
- Mar 2APP - Majority; do pass with amendment(s) but without amendment(s) by Health Care & Wellness.Minor
- Mar 2Executive action taken in the House Committee on Appropriations at 10:30 AM.
- Feb 27Public hearing in the House Committee on Appropriations at 10:30 AM.
- Feb 25Referred to Appropriations.Minor
- Feb 25Minority; without recommendation.Minor
- Feb 25HCW - Majority; do pass with amendment(s).Minor
- Feb 25Executive action taken in the House Committee on Health Care & Wellness at 1:30 PM.
- Feb 18Public hearing in the House Committee on Health Care & Wellness at 1:30 PM.
- Feb 14First reading, referred to Health Care & Wellness.Minor
- Feb 11Third reading, passed; yeas, 48; nays, 1; absent, 0; excused, 0.Minor
- Vote recorded 3rd Reading & Final Passage (#15). Result: pass.Upper
- Feb 11Rules suspended. Placed on Third Reading.Minor
- Feb 11Floor amendment(s) adopted.
- Feb 112nd substitute bill substituted (WM 26).Major
- Feb 6Placed on second reading by Rules Committee.Minor
- Jan 29Passed to Rules Committee for second reading.
- Jan 27Minority; without recommendation.Minor
- Jan 27WM - Majority; 2nd substitute bill be substituted, do pass.Major
- Jan 27Executive action taken in the Senate Committee on Ways & Means at 4:00 PM.
- Jan 12By resolution, reintroduced and retained in present status.
- 2025
- Feb 28Executive session scheduled, but no action was taken in the Senate Committee on Ways & Means at 1:30 PM.
- Feb 26Public hearing in the Senate Committee on Ways & Means at 1:30 PM.
- Feb 21Referred to Ways & Means.Minor
- Feb 21Minority; without recommendation.Minor
- Feb 21And refer to Ways & Means.Minor
- Feb 21HLTC - Majority; 1st substitute bill be substituted, do pass.Major
- Feb 21Executive action taken in the Senate Committee on Health & Long-Term Care at 8:00 AM.
- Feb 7Public hearing in the Senate Committee on Health & Long-Term Care at 8:00 AM.
- Jan 21First reading, referred to Health & Long-Term Care.Introduced
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