Health Plan Prior Authorization Data

In 2020, the Washington State Legislature enacted Engrossed Substitute Senate Bill (ESSB) 6404 (Chapter 316, Laws of 2020, codified at RCW 48.43.0161), which requires that health carriers with at least one percent of the market share in Washington State annually report certain aggregated and de-identified data related to prior authorization to the Office of the Insurance Commissioner (OIC). Prior authorization is a utilization review tool used by carriers to review the medical necessity of requested health care services for specific health plan enrollees.

Carriers choose the services that are subject to prior authorization review. The reported data includes prior authorization information for the following categories of health services: • Inpatient medical/surgical • Outpatient medical/surgical • Inpatient mental health and substance use disorder • Outpatient mental health and substance use disorder • Diabetes supplies and equipment • Durable medical equipment The carriers must report the following information for the prior plan year (PY) for their individual and group health plans for each category of services: • The 10 codes with the highest number of prior authorization requests and the percent of approved requests. • The 10 codes with the highest percentage of approved prior authorization requests and the total number of requests. • The 10 codes with the highest percentage of prior authorization requests that were initially denied and then approved on appeal and the total number of such requests.