Washington State Takes a Leap to Require FHIR APIs and Reshape Prior Authorization

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Washington State has taken a pioneering leap in reshaping the landscape of prior authorization, racing ahead of federal guidelines by mandating the use of FHIR (Fast Healthcare Interoperability Resources) APIs (Application Programming Interfaces). This monumental move, outlined in Engrossed Second Substitute House Bill 1357, not only accelerates the modernization of the prior authorization process but also sets a precedent for nationwide advancements in healthcare technology.

Washington's Forward Leap: A Glimpse into the Future

By laying down a timeline, Washington State’s legislation requires health plans to meet specific deadlines:

By January 1, 2024:

  • Response Timeframes: Health plans must adhere to designated response times for prior authorization requests, particularly focusing on 3-day turnaround for electronic standard requests.
  • Accessibility: Prior authorization requirements must be easily accessible electronically.

By January 1, 2025:

  • API Implementation: Health plans are mandated to have APIs in place to automate segments of the prior authorization process for medical services.

By January 1, 2027:

  • Extended API Integration: APIs must be operational for prescription drug prior authorizations.

However, a contingent clause stipulates that if federal rules on prior authorization APIs weren’t finalized by September 13, 2023, the implementation of API requirements for medical services might be postponed to January 1, 2026.

Key Components and Enforcement

Recent guidance issued by the Commissioner of Insurance details crucial elements of this new policy:

  • Accelerated Timelines: Prior authorization determination timelines have been shortened significantly.
  • Clarity and Communication: There’s a requirement for transparent and electronic sharing of prior authorization criteria.
  • Standardized Criteria: Setting standards for clinical review criteria used in determinations.
  • API Standardization: Carriers must upgrade to standardized interoperability through APIs.

Enforcement Timeline:

  • The Commissioner will begin enforcing most provisions from January 1, 2024.
  • For health plans issued on or after January 1, 2024, new prior authorization timelines will be enforced.
  • Communication and clinical review standards take effect on January 1, 2024.
  • APIs for healthcare services’ prior authorizations will be enforced starting January 1, 2026.
  • APIs for prescription drug prior authorizations will be enforced starting January 1, 2027.

Navigating the Regulatory Maze: Why Monitoring is Crucial

The variances between state laws and final federal rules could pose compliance challenges for health plans. Hence, it's imperative for stakeholders, especially health plans and technology vendors, to vigilantly track the evolution of federal rules alongside state-level policies.

Get Support to Monitor State-Level Policy

POCP’s Prior Authorization Navigator offers subscription monitoring services and specialized expertise in regulatory landscapes. It provides a vigilant eye on rulemaking, offers inputs during proposed and passed policy activity, and ensures consistent updates to subscribers.

Washington’s proactive stance exemplifies the urgency and necessity for healthcare stakeholders to stay abreast of both federal and state-level policies. Embracing evolving technologies like FHIR APIs not only modernizes but also streamlines healthcare processes.

In an era where innovation and compliance walk hand in hand, having a knowledgeable ally like POCP’s Regulatory Resource Center becomes instrumental in navigating the intricate web of regulations, ensuring seamless alignment with both state and federal efforts and the standards being named, and ultimately, advancing healthcare through intelligent technology and informed decisions. Learn more about our Regulatory Resource Center by watching this brief demo video or reach out to me at kim.boyd@pocp.com to talk about policy areas your organization is interested in tracking.