H.R. 5737

119th CONGRESS 1st Session

To amend title XVIII of the Social Security Act to modify data collection requirements for appropriate use criteria for applicable imaging services, and for other purposes.

IN THE HOUSE OF REPRESENTATIVES · October 10, 2025 · Sponsor: Mrs. Harshbarger

Table of contents

• H.R. 5737
  • SEC. 1. Short title
  • SEC. 2. Modification of appropriate use criteria data collection for applicable imaging services

SEC. 1. Short title

• This Act may be cited as the or the .

SEC. 2. Modification of appropriate use criteria data collection for applicable imaging services

• (a) In general
  • Section 1834(q) of the Social Security Act () is amended— 42 U.S.C. 1395m(q)
    • in paragraph (3)(B)(ii)—
      • in subclause (IV), by striking ; and
        • Beginning January 1, 2026, the mechanism provides to the Secretary—
        • the information described in subclauses (III) and (IV);
        • the information described in paragraph (4)(B); and
        • such other information as the Secretary determines to be appropriate, at such time, and in such form and manner, as the Secretary may specify.
      • by adding at the end the following new subclause:
    • in paragraph (4)—
      • (ii) beginning January 1, 2026, comply with such requirements as the Secretary may establish.
      • in subparagraph (A), by striking clause (ii) and inserting the following:
      • in subparagraph (B)—
        • (i) in the heading, by striking and inserting ;
        • (ii) in the matter preceding clause (i)—
        • by striking with January 1, 2017and inserting January 1, 2026; and
        • by striking payment for such service may only be made if the claim for the service includesand inserting the qualified decision support mechanism shall maintain and report to the Secretary under subparagraph (F); and
        • (iii) in clause (iii), by striking ;
          • (iv) An applicable imaging service that is ordered for an individual as part of a clinical trial.
          • (v) An applicable imaging service ordered by an ordering professional practicing in a small practice (consisting of 15 or fewer ordering professionals), or a practice in a health professional shortage area (as designated under section 332(a)(1)(A) of the Public Health Service Act) located in a rural area.
          • (vi) The following types of applicable imaging services:
          • A mammography.
          • A lung cancer screening performed using computed tomography.
          • A colonography performed using computed tomography.
          • Such other preventive or screening imaging services as the Secretary determines appropriate.
      • in subparagraph (C), by adding at the end the following new clauses:
        • (iv) Any other payment system determined appropriate by the Secretary.
      • in subparagraph (D), by adding at the end the following new clause:
        • (E) Furnishing professional requirement
          • Beginning January 1, 2026, with respect to an applicable imaging service furnished in an applicable setting and paid for under an applicable payment system (as defined in subparagraph (D)), the furnishing professional shall include the national provider identifier of the ordering professional (if different from the furnishing professional) on the claim for the service.
        • (F) Reporting requirements
          • The Secretary shall provide, through guidance or rulemaking, information on appropriate ways that each qualified clinical decision support mechanism may report the information maintained under subparagraph (B) to the Secretary to support the Secretary in implementing paragraphs (5) and (6).
      • by adding at the end the following new subparagraphs:
    • in paragraph (5)—
      • in the heading, by striking and inserting ;
        • (A) In general
          • With respect to applicable imaging services furnished on or after January 1, 2026, the Secretary shall determine on an annual basis the total number of ordering professionals who are designated as low compliant ordering professionals under subparagraph (B).
        • (B) Low compliant ordering professionals
          • The Secretary shall designate ordering professionals with a compliance rate (as determined under subparagraph (D)) lower than an amount determined by the Secretary as low compliant ordering professionals.
      • by striking subparagraphs (A) and (B) and inserting the following:
      • in paragraph (C), by striking outlierand inserting low compliant;
        • (D) Determination of compliance rate
          • (i) In general
            • For applicable imaging services furnished on or after January 1, 2026, the Secretary shall determine a compliance rate (as defined in clause (ii)) for each ordering professional for a period specified by the Secretary.
            • In determining a compliance rate for an ordering professional under subclause (I), the Secretary shall use data made available to the Secretary by qualified clinical decision support mechanisms published in the list under paragraph (3)(C) that were consulted by the ordering professional for the period specified by the Secretary under subclause (I).
          • (ii) Definition of compliance rate
            • In this subparagraph, the term compliance rate means, with respect to the requirement that an ordering professional consult with a qualified decision support mechanism when ordering an applicable imaging service under paragraph (4)(A)(i), the ratio (expressed as a percentage) of—
            • the number of claims for orders for an applicable imaging service from such ordering professional during the period specified by the Secretary under clause (i)(I) that provided the qualified decision support mechanism consulted by such ordering professional; and
            • the total number of orders for an applicable imaging service from such ordering professional during such period.
            • In calculating the compliance rate for an ordering professional under subclause (I), the Secretary shall exclude from the total number of orders in item (bb) of such subclause any order for an applicable imaging service described in paragraph (4)(C).
      • by striking subparagraph (D) and inserting the following:
      • in subparagraph (E), by striking outlierand inserting low compliant;
      • (6) Study and report on low compliant ordering professionals and utilization of applicable imaging services
        • (A) In general
          • Not later than January 1, 2031, and every 5 years thereafter, the Secretary shall conduct a study regarding the compliance rates calculated under paragraph (5) and submit a report to Congress that—
            • (i) discusses—
            • such rates and compliance with this subsection;
            • the impact this subsection has on the utilization of applicable imaging services; and
            • potential mechanisms for improving compliance with this subsection, including—
            • prior authorization for applicable imaging services ordered by low compliant ordering professionals;
            • any payment adjustment related to the services, or a subset of services, that the Secretary may designate under the fee schedule under section 1848; or
            • other mechanisms determined appropriate by the Secretary; and
            • (ii) proposes alternative compliance rate thresholds for low compliant ordering professionals for purposes of paragraph (5)(B).
    • by striking paragraph (6) and inserting the following:
      • (8) Specialty society endorsement
        • In specifying applicable appropriate use criteria for applicable imaging services under paragraph (2) and qualified clinical decision support mechanisms under paragraph (3), the Secretary shall substantially adhere to the approach described in section 414.94 of title 42, Code of Federal Regulations (as in effect on January 1, 2023).
        • Specialty society endorsement
    • by adding at the end the following new paragraph:
• (b) Effective date
  • The amendments made by subsection (a) shall take effect on January 1, 2026.