70.14.120 - Agency compliance with committee determination -- Coverage and reimbursement determinations for nonreviewed health technologies -- Appeals.

Agency compliance with committee determination — Coverage and reimbursement determinations for nonreviewed health technologies — Appeals.

(1) A participating agency shall comply with a determination of the committee under RCW 70.14.110 unless:

     (a) The determination conflicts with an applicable federal statute or regulation, or applicable state statute; or

     (b) Reimbursement is provided under an agency policy regarding experimental or investigational treatment, services under a clinical investigation approved by an institutional review board, or health technologies that have a humanitarian device exemption from the federal food and drug administration.

     (2) For a health technology not selected for review under RCW 70.14.100, a participating agency may use its existing statutory and administrative authority to make coverage and reimbursement determinations. Such determinations shall be shared among agencies, with a goal of maximizing each agency's understanding of the basis for the other's decisions and providing opportunities for agency collaboration.

     (3) A health technology not included as a covered benefit under a state purchased health care program pursuant to a determination of the health technology clinical committee under RCW 70.14.110, or for which a condition of coverage established by the committee is not met, shall not be subject to a determination in the case of an individual patient as to whether it is medically necessary, or proper and necessary treatment.

     (4) Nothing in chapter 307, Laws of 2006 diminishes an individual's right under existing law to appeal an action or decision of a participating agency regarding a state purchased health care program. Appeals shall be governed by state and federal law applicable to participating agency decisions.

[2006 c 307 § 5.]

Notes: Captions not law -- Conflict with federal requirements -- 2006 c 307: See notes following RCW 70.14.080.