WSR 26-22-053: Prior Authorization Turnaround Times

Washington State Health Care Authority (HCA) adopted permanent amendments to WAC 182-501-0160 and WAC 182-501-0165, effective January 1, 2027, to comply with the federal CMS-0057-F final rule, Advancing Interoperability and Improving Prior Authorization, codified at 42 CFR § 440.230(e)(4). The rulemaking was filed October 29, 2026, under statutory authority of RCW 41.05.021 and RCW 41.05.160, and amends two existing sections without adding or repealing any WAC sections. For exception-to-rule (ETR) requests under WAC 182-501-0160, the amended rule compresses the initial response window from fifteen business days to seven calendar days. The time allowed for a provider to submit additional information requested by the agency is reduced from thirty calendar days to seven calendar days. Following receipt of that additional information, the agency must approve or deny within seven calendar days, replacing the prior five-business-day standard. Failure to provide the requested information within seven calendar days results in denial of the ETR request. For fee-for-service prior authorization (PA) determinations under WAC 182-501-0165, the rule establishes two tracks. Standard PA requests must be resolved as expeditiously as the client's health condition requires, but no later than seven calendar days from receipt, replacing the former fifteen-day window. Expedited authorization requests must be resolved within 72 hours of receipt. Providers must submit any additional information requested within seven calendar days; upon receipt, the agency has seven calendar days to approve or deny, replacing the former five-business-day window. Denial notices under WAC 182-501-0165 must now be sent within seven calendar days of the date information is received, replacing the prior ten-business-day standard. The notice must include the factual basis for the denial, the specific WAC provision cited, the client's administrative hearing rights, continuation or reinstatement circumstances, and examples of lesser-cost alternatives.