WSR 26-22-053: Prior Authorization Turnaround Times

The Washington Health Care Authority (HCA) adopted permanent amendments to WAC 182-501-0160 and WAC 182-501-0165, effective January 1, 2027, to align state Medicaid fee-for-service prior authorization and exception-to-rule procedures with the federal CMS-0057-F rule, "Advancing Interoperability and Improving Prior Authorization" (42 CFR § 440.230(e)(4)). The rulemaking was adopted October 29, 2026, under statutory authority RCW 41.05.021 and RCW 41.05.160, with no changes from the proposed version filed as WSR 26-19-090 on September 18, 2026. For standard prior authorization (PA) requests under WAC 182-501-0165, the amended rule shortens the initial determination deadline from 15 calendar days to 7 calendar days of receiving the request. When additional information is requested, the provider must submit it within 7 calendar days (reduced from 30), and the agency must approve or deny within 7 calendar days of receiving that information (reduced from 5 business days). If the provider fails to submit the additional information within 7 calendar days, the agency denies the request. For expedited authorization requests, the agency must act within 72 hours of receiving the request. For exception-to-rule (ETR) requests under WAC 182-501-0160, the initial written notification deadline is shortened from 15 business days to 7 calendar days. Additional information requested from the provider must be received within 7 calendar days (reduced from 30), and the agency must approve or deny within 7 calendar days of receiving that additional information (reduced from 5 business days). If the information is insufficient or not provided within 7 calendar days, the ETR request is denied. The amended WAC 182-501-0165 also adds an explicit requirement that when the agency denies a covered service, written notice to the client and provider must be sent within 7 calendar days of receiving the relevant information (reduced from 10 business days). The denial notice requirements, including the factual basis, applicable WAC citation, hearing rights, continuation of services, and lesser-cost alternatives, are preserved without substantive change.