OIC Issues Proposed Rule on Prior Authorizations

December 16, 2016

Last week the Washington State Office of the Insurance Commissioner (OIC) issued a proposed rule on prior authorizations.  The OIC action follows WSHA and the Washington State Medical Association requests for more scrutiny of insurer practices and a lengthy and comprehensive stakeholder draft process.  OIC will accept comments on the proposed rules through January 4, 2017, the date of the rulemaking hearing.

We are pleased that the OIC has undertaken a rule making process on prior authorization to provide a more uniform, predictable, and transparent process for prior authorizations for providers and patients. The proposed rule includes many important provisions and protections specifically requested by WSHA, including:

  • Third-party benefit managers contracted by carriers are subject to the same requirements as the carrier itself
  • Changes to prior authorizations are subject to same notification requirements as contract amendments
  • Carriers must provide greater transparency of clinical criteria and pre-service requirements for services subject to prior authorization
  • Carriers are required to provide retrospective review when extenuating circumstances prevent the provider from obtaining prior authorization in advance of service

Following the completion of the comment period, OIC will make revisions and issue a final rule. (Andrew Busz, andrewb@wsha.org)


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