Washington State Health Plan Prior Authorization Statistics

State of Washington Office of the Insurance Commissioner collects annual reports from health carriers covering at least one percent of the state's market share. The dataset includes aggregated data on prior authorization requests, approval rates, appeal outcomes, and average response times for six categories of health services. Data is reported for individual and group health plans.

Use Cases

• Analyze approval rates for the 10 codes with the highest number of prior authorization requests across service categories like inpatient medical/surgical or durable medical equipment.
• Compare average response times in hours for expedited, standard, and extenuating-circumstances decisions for outpatient mental health and substance use disorder services.
• Identify service codes with the highest percentage of requests initially denied but approved on appeal to study carrier appeal processes.

Strengths

• Data is mandated by state law (ESSB 6404), ensuring consistent reporting from major market participants.
• Reports cover six distinct service categories, including mental health, substance use disorder, and medical equipment.
• Includes multiple metrics per service code: request counts, approval percentages, appeal outcomes, and decision timeliness.

Limitations

• Data is aggregated and de-identified, preventing analysis at the individual patient or claim level.
• Reporting is limited to carriers with at least 1% market share in Washington, excluding smaller insurers.
• Sample data and specific record counts are unavailable, making it difficult to assess dataset scale.

Provenance

Source

State of Washington Office of the Insurance Commissioner (OIC).

Collection Method

Mandated annual reporting by health carriers under RCW 48.43.0161.

Time Range

Plan year data; reporting began for 2020 and includes prescription drug data from 2024.

Freshness

Updated annually; last metadata update was 2026-01-03.

Geography

Washington State, USA.