Washington State Health Plan Prior Authorization Rates And Response Times

Washington State health carriers report aggregated prior authorization data annually to the Office of the Insurance Commissioner. The dataset covers six service categories, including inpatient/outpatient medical-surgical and mental health services, detailing top codes by request volume, approval rates, and appeal outcomes. Reporting is mandated by state law (ESSB 6404) for carriers with at least one percent market share.

Use Cases

• Analyze approval rate disparities across Service categories like 'Inpatient mental health and substance use disorder' versus 'Outpatient medical/surgical'.
• Model average response times by comparing Expedited - Avg response time, Standard - Avg response time, and Extenuating circumstances - Avg response time columns.
• Identify high-volume, low-approval services by joining Number of requests per code and Approval rate for specific Codes and Descriptions.
• Track appeal success rates by examining the Initially denied then approved - approval rate column for top codes.
• Compare carrier performance by aggregating metrics like Approval rate and Number of requests per code grouped by the Carrier field.

Strengths

• Data covers six distinct Service categories, enabling cross-category analysis.
• Includes three decision types (Expedited, Standard, Extenuating-circumstances) with separate average response time and request count columns.
• Reports the top 10 codes by three different metrics (volume, approval rate, appeal success) per category.

Limitations

• Sample size is unknown, limiting statistical reliability assessments.
• Data is aggregated and de-identified, preventing patient-level or detailed clinical analysis.
• Geographic scope is limited to Washington State, reducing national generalizability.

Provenance

Source

Washington State Office of the Insurance Commissioner via data.wa.gov.

Collection Method

Mandated annual reporting by health carriers with at least one percent market share, as required by state law ESSB 6404.

Time Range

Covers prior plan years; specific start year unknown.

Freshness

Updated annually; last update was 2025-12-29.

Geography

Washington State, USA.