Washington Law Says AI Shall Not Be the Sole Means to Deny, Delay or Modify Care

Washington has a law on how health carriers decide prior authorization requests. The law defines a standard request of that kind. It is one by a provider or facility for approval of a health care service or a prescription drug. It is made before the enrollee obtains the service or drug, and is not required to be expedited. The law is chapter 157 of Washington's Laws of 2026, passed as Engrossed Second Substitute Senate Bill 5395. The governor approved it on March 23, 2026. It took effect on June 11, 2026, except for two sections that take effect on January 1, 2027.

Only a licensed physician, or a licensed health professional working within their scope of practice, may deny a prior authorization request based on medical necessity. The licensed physician or licensed health professional shall evaluate the specific clinical issues involved in the services requested. They do so by reviewing and considering the requesting provider's recommendation. They also review and consider the enrollee's medical or other clinical history, as applicable, and the individual clinical circumstances.

Artificial intelligence "shall not be the sole means" used to deny, delay or modify health care services. Algorithms may be used to process and approve requests. They may not be used without human review to deny care based on medical necessity. Parts of the law follow, not the whole.

The Legislature's Findings and Intent

The law opens with findings. Health carriers decide the type and level of care covered for an enrollee's benefits, it says. They are not responsible for determining or altering the enrollee's diagnosis or treatment plan. It is not always transparent who the decision maker is, or how coverage decisions are made. And carriers are increasingly using AI to make or aid such decisions. The law names decisions about medical necessity and about coverage of the treatment a provider recommends.

The legislature then states its intent. It wants more transparency in prior authorization. It wants licensed physicians and licensed health professionals to remain responsible for decisions on treatments, prescription drugs and other health care services. If AI aids the decision, standards must be put in place. They are to ensure that AI is not used to make inappropriate determinations that could affect an enrollee's health.

The legislature also states an intent to update the law's protections for enrollees to include managed care organizations as soon as feasible.

The Rule and Its Reach

The law defines artificial intelligence as the use of machine learning and related technologies that use data to train statistical models. The purpose is to let computer systems perform tasks normally associated with human intelligence or perception. It gives examples such as computer vision, speech or natural language processing, and content generation. Generative AI is included.

The carrier section does not apply to prior authorization determinations made under RCW 48.43.761. It does apply to prior authorization functions carried out by health care benefit managers. That covers managers under a direct or indirect contract with a carrier. A second section carries the same denial rule and conditions on AI, worded for its own plans and with its own exceptions. It covers health plans offered to public employees, retirees and their covered dependents.

Eight Things a Carrier Must Ensure

The conditions apply when a carrier uses AI for prior authorization or its functions based in whole or in part on medical necessity. They apply too where the carrier contracts with or otherwise works through an entity that uses AI for prior authorization or its functions on that same basis. Either way, the law says, the carrier shall ensure all of the following.

The AI bases its determination, as applicable, on the enrollee's medical or other clinical history, including demographic data. It also bases it, as applicable, on the individual clinical circumstances as presented by the requesting provider. It does not base its determination solely on a group data set. Its criteria and guidelines comply with the chapter and with applicable state and federal law. Its use does not discriminate, directly or indirectly, against an enrollee in violation of state or federal law. It is fairly and equitably applied, including under any applicable regulations and guidance of the federal Department of Health and Human Services.

The policies and procedures for using the AI are open to audit by the office of the insurance commissioner. The carrier periodically reviews the AI's performance, use and outcomes to maximize accuracy and reliability. And patient data is not used beyond its intended and stated purpose. That use must be consistent with chapter 70.02 RCW and the federal Health Insurance Portability and Accountability Act of 1996, as applicable.

The duty stays with the carrier. A carrier that works through an entity using AI still has to ensure all of them. What its contract lets it see becomes part of the answer.

The Yearly Report

Some carriers report to the insurance commissioner each year. The law sets a size test for them, based on their share of the accident and health insurance premiums written in Washington. The report holds aggregated and deidentified data on their prior authorization practices and experience for the prior plan year. As amended, the section says the report is due by October 1, 2026, and annually after that.

In the report, carriers must also indicate the percentage of total denials that were aided by artificial intelligence.

A share of denials aided by AI is a number a carrier has to be able to count.