BILL REQ. #:  S-1566.1 

READ FIRST TIME 02/22/13.   

     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 November 15, 2013, the lead organization shall present to the commissioner a plan for the implementation of a uniform electronic prior authorization form and data fields for prescription drug benefits. The commissioner shall review the plan and determine if it meets the criteria required in this section. If the commissioner determines that the criteria have been met, then the uniform electronic prior authorization process shall be implemented no later than May 15, 2014.
     (a) The plan presented by the lead organization shall contain the following elements:
     (i) There must be a defined response time for prior authorization approval or denial that shall not exceed the review time frames under WAC 284-43-410(6). No response within the given time frame deems the prior authorization approved;
     (ii) There must be data elements, not to exceed the equivalent of two pages, that are electronically submissible;
     (iii) The plan must be capable of being electronically accepted by the payor after being completed; and
     (iv) The plan must be in compliance with national council for prescription drug programs prior authorization transactions for the national council for prescription drug programs SCRIPT standard.
     (b) All forms and data fields must 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, all of whom have been actively practicing in their specialty for a minimum of five years.
     (c) If the lead organization does not present a plan that meets the criteria required in this section to the commissioner by November 15, 2013, the commissioner shall establish a uniform electronic prior authorization process that meets the criteria by no later than May 15, 2014. If the lead organization establishes a plan that meets the criteria required in this section, the commissioner shall require third-party payors or any third party entity acting on behalf of a payor under contract to use and accept only the forms developed in accordance with this section.