WA SB5395: Making improvements to transparency and accountability in the prior authorization determination process.

In one paragraph

Chapter 157, Laws of 2026 regulates AI in health insurance prior authorization (RCW 48.43.830 for carriers and RCW 41.05.845 for public employee plans). AI may not be the sole means of denying, delaying or modifying care, and algorithms may approve requests but may not deny care for medical necessity without human review. A carrier using AI must base decisions on the enrollee's clinical history and individual clinical circumstances, not solely on group data; avoid discrimination; open its AI policies to audit by the Insurance Commissioner; and periodically review AI performance. Carriers must report the share of denials aided by AI (RCW 48.43.0161).

Plain-English summary, written with AI assistance. The official text controls.

What it means for business

Health insurers and their utilization review vendors in Washington must keep humans in AI-assisted denials, document AI criteria and report AI-aided denial rates.

Key provisions

1. 1AI may not be the sole means used to deny, delay or modify health care services
2. 2Algorithms may approve prior authorization requests but may not deny care on medical necessity without human review
3. 3AI must base decisions on the enrollee's medical or clinical history and the individual clinical circumstances presented by the provider, not solely on a group data set
4. 4AI use must not discriminate and must be fairly and equitably applied
5. 5AI policies and procedures are open to audit by the Office of the Insurance Commissioner; performance must be periodically reviewed
6. 6Applies to health carriers (RCW 48.43.830) and public employee health plans (RCW 41.05.845)
7. 7Carriers must report the percentage of denials aided by artificial intelligence (RCW 48.43.0161)
8. 8Effective June 11, 2026; sections 3 and 7 take effect January 1, 2027

Latest legislative action

Mar 23, 2026. Governor signed. Chapter 157, 2026 Laws. Effective date 6/11/2026.