What is prior authorization?
Prior authorization (PA) means the health plan must approve certain care before it will cover it. Providers often submit requests for you, but you still have rights if PA is denied or delayed.
Overview: Prior authorizations. Washington-only details below.
Confirm plan type: Washington: Start Here.
Washington PA rules
Washington's main PA statute is RCW 48.43.830 (enacted through HB 1357, 2023). It applies to health plans issued or renewed in Washington on or after January 1, 2024, with full operational compliance required by January 1, 2027—not Medicare, Medicaid, TRICARE, or typical large self-funded ERISA plans.
Decision timeframes (RCW 48.43.830)
- Electronic PA: decision within 3 calendar days (standard) or 1 calendar day (expedited) after a complete submission
- Non-electronic PA: decision within 5 calendar days (standard) or 2 calendar days (expedited) after a complete submission
- Carriers must notify providers when submissions are incomplete so requests do not stall
- Clinical criteria must be evidence-based, peer-reviewed, and updated at least annually; PA lists posted centrally on carrier websites
Electronic prior authorization (ePA)
Carriers must build PA application programming interfaces integrated with provider EHR/practice systems—medical services by January 1, 2025, with broader requirements phasing through 2027. Carriers may not charge providers fees to access ePA tools.
Prescription drug PA
Washington also regulates drug PA through carrier contract requirements (similar themes: timely decisions, ePA, public PA lists). Check your plan's pharmacy benefit manager portal and the WSMA Prior Authorization Navigator for carrier-specific rules and complaint tools.
Step therapy & other protections
Carriers must provide clear step therapy exception processes. Ongoing legislative proposals (e.g., SB 5395 / HB 1566 in 2025) would further limit AI-only denials and retroactive clawbacks—check current law on your denial date.
Federal deadlines (some plans)
Federally regulated plans may also follow CMS timing: 72 hours urgent / 7 calendar days standard for many impacted payers.
Washington has not enacted a statewide gold-carding law for medical PA as of 2026.
Where to look up PA rules
Check your plan materials and the carrier's provider or member portal. Carriers must post current PA requirements and clinical criteria in an electronic format upon request.
Carrier links: Washington prior auth & internal appeals links.
Medicaid
Apple Health managed care uses separate utilization management and MCO appeal rules through HCA—not commercial RCW 48.43.830 PA deadlines for most member benefit disputes.
If PA is denied
Appeal through your plan's internal grievance process, then certified independent review if needed.
Next: Washington internal appeals.
Urgent care
Emergency care cannot require prior authorization. For urgent PA, Washington law targets 1–2 calendar day decisions depending on submission method. For urgent medical necessity disputes after a denial, request expedited internal appeal and may qualify for 72-hour IRO review.