BILL REQ. #:  S-1966.1 

READ FIRST TIME 03/01/13.   

     AN ACT Relating to developing standardized prior authorization for medical and pharmacy management; and amending RCW 48.165.050.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

Sec. 1   RCW 48.165.050 and 2009 c 298 s 10 are each amended to read as follows:
     (1) By December 31, 2010, the lead organization shall:
     (a) Develop and promote widespread adoption by payors and providers of guidelines to:
     (i) Ensure payors do not automatically deny claims for services when extenuating circumstances make it impossible for the provider to: (A) Obtain a preauthorization before services are performed; or (B) notify a payor within twenty-four hours of a patient's admission; and
     (ii) Require payors to use common and consistent time frames when responding to provider requests for medical management approvals. Whenever possible, such time frames shall be consistent with those established by leading national organizations and be based upon the acuity of the patient's need for care or treatment;
     (b) Develop, maintain, and promote widespread adoption of a single common web site where providers can obtain payors' preauthorization, benefits advisory, and preadmission requirements;
     (c) Establish guidelines for payors to develop and maintain a web site that providers can employ to:
     (i) Request a preauthorization, including a prospective clinical necessity review;
     (ii) Receive an authorization number; and
     (iii) Transmit an admission notification.
     (2) By October 31, 2010, the lead organization shall propose to the commissioner a set of goals and work plan for the development of medical management protocols, including whether to develop evidence-based medical management practices addressing specific clinical conditions and make its recommendation to the commissioner, who shall report the lead organization's findings and recommendations to the legislature.
     (3) By December 31, 2013, the lead organization and the work group convened by the lead organization shall present to the executive oversight committee a plan for the implementation of a uniform electronic prior authorization form or electronic process for prescription drug benefits. The executive oversight committee shall review the plan and form and determine if the form or process meets the criteria required in this section. Carriers may submit an electronic prior authorization form already in use or in development to the work group for its consideration. If the executive oversight committee determines that the criteria for the form or process have been met, then the uniform electronic prior authorization process and form shall be developed and released by the work group convened by the lead organization for use by payors. Payors must implement the form and process no later than January 1, 2015.
     (a) The form or process presented by the work group convened by the lead organization shall contain the following elements:
     (i) Be capable of being electronically accepted by the payor after being completed;
     (ii) Be able to be submitted in real time;
     (iii) Have the option of prepopulating certain data fields with medication information once the drug is selected;
     (iv) Be capable of attaching supporting documentation, chart notes, and files to the electronic form;
     (v) After submitting the form, the provider shall receive an acknowledgment of receipt, which includes carrier contact information for addressing concerns related to the prior authorization form; and
     (vi) The form or process shall include the following standard data fields, as necessary: Member information; prescribing provider information; requested medication, strength, and dosing schedule; diagnosis related to use; prior medications tried; and supporting clinical information.
     (b) The form developed by the work group shall be developed in consultation with health care providers licensed under chapter 18.71 or 18.57 RCW who are board certified and recommended by the Washington state medical association, and a health care provider licensed under chapter 18.64 RCW.
     (c) If the lead organization does not present a plan and form that meets the criteria required in this section by December 31, 2013, the commissioner shall establish a uniform electronic prior authorization process that meets the criteria by no later than January 1, 2015.
     (d) There must be a defined response time for prior authorization approval or denial as set forth under WAC 284-43-410(6). No response within the given time frame deems the prior authorization approved.
     (e) A carrier or third-party entity acting on its behalf must be exempted from the requirements of this section if the executive oversight committee convened by the commissioner finds the carrier or third-party entity has implemented an electronic prior authorization form for prescription drugs by December 31, 2015, that meets the criteria in (a) of this subsection.
     (f) The provisions of this subsection (3) do not apply to industrial insurance benefits provided under Title 51 RCW or to victims of crimes benefits provided under chapter 7.68 RCW.