{"@type": "dcat:Dataset", "accessLevel": "public", "contactPoint": {"@type": "vcard:Contact", "fn": "Simon Casson", "hasEmail": "mailto:no-reply@data.wa.gov"}, "description": "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:<br>\n\u2022\tInpatient medical/surgical <br>\n\u2022\tOutpatient medical/surgical <br>\n\u2022\tInpatient mental health and substance use disorder <br>\n\u2022\tOutpatient mental health and substance use disorder <br>\n\u2022\tDiabetes supplies and equipment <br>\n\u2022\tDurable medical equipment <br><br>\n\nThe carriers must report the following information for the prior plan year (PY) for their individual and group health plans for each category of services:<br>\n\u2022\tThe 10 codes with the highest number of prior authorization requests and the percent of approved requests.<br>\n\u2022\tThe 10 codes with the highest percentage of approved prior authorization requests and the total number of requests.<br>\n\u2022\tThe 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. <br><br>\n\nCarriers also must include the average response time in hours for prior authorization requests and the number of requests for each covered service in the lists above for:<br>\n\u2022\tExpedited decisions. <br>\n\u2022\tStandard decisions. <br>\n\u2022\tExtenuating-circumstances decisions.<br><br>\n\nEngrossed Second Substitute House Bill 1357 added additional prescription drug prior authorization reporting requirements for health carriers beginning in reporting year 2024.", "distribution": [{"@type": "dcat:Distribution", "downloadURL": "https://data.wa.gov/api/views/fysr-7kwx/rows.csv?accessType=DOWNLOAD", "mediaType": "text/csv"}, {"@type": "dcat:Distribution", "describedBy": "https://data.wa.gov/api/views/fysr-7kwx/columns.rdf", "describedByType": "application/rdf+xml", "downloadURL": "https://data.wa.gov/api/views/fysr-7kwx/rows.rdf?accessType=DOWNLOAD", "mediaType": "application/rdf+xml"}, {"@type": "dcat:Distribution", "describedBy": "https://data.wa.gov/api/views/fysr-7kwx/columns.json", "describedByType": "application/json", "downloadURL": "https://data.wa.gov/api/views/fysr-7kwx/rows.json?accessType=DOWNLOAD", "mediaType": "application/json"}, {"@type": "dcat:Distribution", "describedBy": "https://data.wa.gov/api/views/fysr-7kwx/columns.xml", "describedByType": "application/xml", "downloadURL": "https://data.wa.gov/api/views/fysr-7kwx/rows.xml?accessType=DOWNLOAD", "mediaType": "application/xml"}], "identifier": "https://data.wa.gov/api/views/fysr-7kwx", "issued": "2024-12-17", "keyword": ["health", "insurance", "insurance commissioner", "prior authorization"], "landingPage": "https://data.wa.gov/d/fysr-7kwx", "modified": "2025-12-29", "publisher": {"@type": "org:Organization", "name": "data.wa.gov"}, "theme": ["health"], "title": "Health Plan Prior Authorization Data"}