WA SB5395

Prior authorization denials based on medical necessity must be made only by licensed physicians or health professionals who review the individual patient's clinical circumstances, with AI prohibited from being the sole means to deny, delay, or modify care

New prior authorization requirements can only take effect quarterly (January 1st, April 1st, July 1st, or October 1st) starting August 2025, with providers receiving at least 45 days advance notice of policy changes

Carriers using AI for prior authorization must ensure determinations consider individual patient history rather than solely group data sets, and AI systems must be open to audit by the Insurance Commissioner

Denial notifications must include credentials, board certifications, and specialty training of the provider who had clinical oversight over the determination

Carriers must report annually on prior authorization statistics including total requests, approvals, denials, percentage of denials aided by AI, and response times for standard versus expedited requests