AN ACT Relating to the creation of a demonstration project to promote the use of appropriate use criteria for cardiac diagnostic imaging procedures; and adding a new section to chapter 41.05 RCW.

(1) The legislature intends to create a demonstration project within the public employees' benefits board that would replace current health plan prior authorization standards for noninvasive cardiac diagnostic imaging procedures with the use of selected appropriate use criteria.

(2) The authority may adopt rules to establish the demonstration project and implement this section. In adopting rules the authority may consult stakeholders including health carriers, health care practitioners, health systems, and patients.

(4) By January 1, 2021, the authority must establish and implement the appropriate use criteria demonstration project for noninvasive cardiac diagnostic imaging procedures. The demonstration project must:

(a) Require participating health care providers who seek to order a noninvasive cardiac diagnostic imaging procedure for a covered patient to use the appropriate use criteria selected by the authority to determine if a noninvasive cardiac diagnostic imaging procedure is appropriate;

(b) Prohibit participating health carriers from denying a noninvasive cardiac diagnostic imaging procedure for purposes of prior authorization or approval if the health care provider used the appropriate use criteria selected by the authority and the procedure was determined to be appropriate for the covered patient; and

(c) Allow a health carrier to deny a claim for purposes other than prior authorization including, but not limited to, submission of duplicative claims or termination of coverage.

(5) The demonstration project may allow a health carrier to conduct a periodic, independent audit of claims ordered through the demonstration project.

(6) The authority must evaluate the impact of the demonstration project including the impact on patients, and any increase or decrease in expenses and the use of noninvasive cardiac diagnostic imaging. The authority must report to the legislature on the results of the evaluation by October 1, 2023. The report must include findings from the demonstration project, including recommendations for modifying or expanding the project.

(7) Any electronic tools, such as clinical decision support mechanisms, used in the demonstration project must meet all privacy and security standards required under applicable state and federal law.

(8) The authority may solicit and accept funding and in-kind contributions to support the demonstration and evaluation, and may scale the evaluation to fall within resulting resource parameters.

(a) "Appropriate use criteria" means criteria only developed or endorsed by a provider-led entity that is approved by the authority, to assist health care practitioners in making the most appropriate treatment decision for a specific clinical condition for an individual. To the extent feasible, such criteria must be evidence-based.

(b) "Clinical decision support mechanism" means an interactive, electronic tool for use by clinicians that communicates selected appropriate use criteria information to the user and assists them in making the most appropriate treatment decision for a patient's specific clinical condition.

(c) "Provider-led entity" means a cardiac-specific national professional medical specialty society or organization that is comprised primarily of providers or practitioners who, either within the organization or outside of the organization, predominantly provide direct patient care that is qualified by the centers for medicare and medicaid services to provide appropriate use criteria under 42 C.F.R. Part 414.94.