WSHA comments on OIC Prior Authorization Rules Stakeholder Draft

October 19, 2016

On September 23, the Office of the Insurance Commissioner (OIC) released a third iteration of stakeholder draft rules concerning prior authorizations. We are pleased that the OIC has undertaken a rule making process on prior authorization and is trying to provide more transparency around some of the requirements. The latest draft maintains many important provisions and protections specifically requested by WSHA, including:

  • Carriers would have greater accountability for prior authorization reviews by third-party benefit managers and contractors
  • Changes to prior authorizations would be 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 would be required to provide retrospective review when extenuating circumstances prevent the provider from obtaining prior authorization in advance of services

We are disappointed that the draft does not do more to require carriers to provide clinical and financial justification for new requirements, but believe the draft rule is a big step forward to increasing transparency and accountability. WSHA submitted a comment letter supporting the changes and testified at an October 5 stakeholder meeting.

We believe the OIC will next make some additional changes based on stakeholder comments and issue a proposed rule as part of the formal (CR-102) rulemaking process. (Andrew Busz,


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