ESSB 6511 -
By Committee on Health Care & Wellness
ADOPTED AS AMENDED 03/06/2014
Strike everything after the enacting clause and insert the following:
"NEW SECTION. Sec. 1 A new section is added to chapter 48.165
RCW to read as follows:
(1) The insurance commissioner must reauthorize the efforts with
the lead organization established in RCW 48.165.030, and establish a
new work group to develop recommendations for prior authorization
requirements. The focus of the prior authorization efforts must
include the full scope of health care services including pharmacy
issues. The work group must submit recommendations to the commissioner
by October 31, 2014.
(2) The lead organization and work group established to review
prior authorization requirements must consider the following areas in
their efforts:
(a) Requiring carriers and pharmacy benefit managers to provide a
listing of prior authorization requirements electronically on a web
site. The listing of requirements for any procedure, supply, or
service requiring preauthorization must include criteria needed by the
carrier specific to that medical or procedural code, to allow a
provider's office to submit all information needed on the initial
request for prior authorization, along with instructions for submitting
that information;
(b) Requiring a carrier or pharmacy benefit manager to issue an
acknowledgement of receipt or reference number for prior authorization
within a specified time frame, such as two business days of receipt of
a prior authorization request from a provider;
(c) Recommendations for the best practices for exchanging
information, including alternatives to fax requests;
(d) Recommendations for the best practices if the acknowledgement
has not been received by the provider or pharmacy benefit manager
within the specified time frame, such as two business days;
(e) Recommendations if the carrier or pharmacy benefit manager
fails to approve, deny, or respond to the request for authorization
within the specified time frame and options for deeming approval;
(f) Recommendations to refine the time frames in current rule; and
(g) Recommendations specific to pharmacy services, including
communication between the pharmacy to the carrier or pharmacy benefit
manager, communications between the carrier or pharmacy benefit manager
with the providers' office, communication of the authorization number,
posting of the criteria for pharmacy related prior authorization on a
web site and other recommended alternatives; and options for prior
authorizations involving urgent and emergent care with short-term
prescription fill, such as a three-day supply, while the authorization
is obtained.
(3) In preparing the recommendations, the work group must consider
the opportunities to align with national mandates and regulatory
guidance in the health insurance portability and accountability act and
the patient protection and affordable care act, and use information
technologies and electronic health records to increase efficiencies in
health care and reengineer and automate age-old practices to improve
business functions and ensure timely access to care for patients.
(4) The commissioner shall adopt rules implementing the
recommendations of the work group. The rules adopted under this
subsection may only implement, and may not expand or limit, the
recommendations of the work group.
NEW SECTION. Sec. 2 A new section is added to chapter 48.43 RCW
to read as follows:
(1) A health carrier may not directly, indirectly through
contracted networks, or otherwise require a covered person to obtain
prior authorization for routine health care services for which a person
may self refer.
(2) A carrier, whether directly or indirectly through subcontracted
networks, shall disclose:
(a) Its criteria and methods for establishing limits on access to
network providers, including, but not limited to, the carrier's method
used to determine that a network provider may provide care to a covered
person without prior authorization while imposing prior authorization
requirements on other network providers; and
(b) Its methods and clinical protocols for authorizing coverage of
health care services, including, but not limited to, the carrier's
method for determining initial visit limits for a particular health
care service."
Correct the title.
EFFECT: Removes the requirement that the work group make recommendations to limit or eliminate the application of prior authorization to routine health care services for which a person may self-refer. Requires the Insurance Commissioner (Commissioner) to adopt rules implementing the recommendations of the work group (the underlying bill required the Commissioner to revise the rules for prior authorization with the work group's recommendations). Prohibits the rules from expanding or limiting the work group's recommendations. Prohibits health carriers from requiring prior authorization for routine health care services for which a person may self-refer. Requires a carrier to disclose: (1) Its criteria and methods for establishing limits on access to network providers, including the carrier's method to determine that a network provider may provide care to a covered person without prior authorization while imposing prior authorization requirements on other network providers and (2) its methods and clinical protocols for authorizing coverage of health care services, including the carrier's method for determining initial visit limits.