,,ii ,cal5d> ,no4 #cag #aad? ,,congress #a/ ,session ,s4 #bcfh ,report ,no4 #aad-agg ,,9 ,,! ,,s5ate ,,( ,,! ,,unit$ ,,/ates ,decemb] #h1 #bjae ,mr4 ,hat*1 f ! ,committee on ,f9ance1 report$ ! foll[+ orig9al bill2 :i* 0 read twice & plac$ on ! cal5d> ,a ,,bill ,to am5d title ,,xviii ( ! ,social ,security ,act to improve ! effici5cy ( ! ,m$ic>e appeals process1 & = o!r purposes4 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,audit ,appeals ,fairness1 ,integrity1 & ,re=ms 9 ,m$ic>e ,act ( #bjae or ! ,,afirm ,act4 7b7 ,table ( cont5ts ,! table ( cont5ts = ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4 ,sec4 #b4 ,increas$ res\rces = ! ,(fice ( ,m$ic>e ,he>+s & ,appeals & ! ,dep>tm5tal ,appeals ,bo>d4 ,sec4 #c4 ,e/abli%m5t ( ,m$ic>e magi/rate review & revision ( am\nt 9 controv]sy ?re%olds4 ,sec4 #d4 ,rem&+ appeals to ! r$et]m9ation level ) ! introduction ( new evid5ce4 ,sec4 #e4 ,exp$it$ access to appeals4 ,sec4 #f4 ,au?ority to use sampl+ & extrapolation me?odologies & to consolidate appeals = adm9i/rative effici5cy4 ,sec4 #g4 ,id5tification & ref]ral ( fraud4 ,sec4 #h4 ,/udy to assess he>+ p>ticipation4 ,sec4 #i4 ,improvem5ts to ! ,(fice ( ,m$ic>e ,he>+s & ,appeals4 ,sec4 #aj4 ,review program improvem5ts4 ,sec4 #aa4 ,creation ( ,m$ic>e ,provid] & ,suppli] ,ombudsman = ,reviews & ,appeals4 ,sec4 #ab4 ,limit+ ! audit & recov]y p]iod = pati5t /atus reviews4 ,sec4 #ac4 ,inc5tives & dis9c5tives = ,m$ic>e contractors1 provid]s1 & suppli]s4 #b4 ,increas$ res\rces = ! ,(fice ( ,m$ic>e ,he>+s & ,appeals & ! ,dep>tm5tal ,appeals ,bo>d 7a7 ,9 g5]al ,= fiscal ye> #bjaf & = ea* fiscal ye> !reaft]1 = purposes ( conduct+ reviews1 he>+s1 & appeals "u title ,,xviii ( ! ,social ,security ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices %all provide = ! transf] f ! ,f$]al ,hospital ,insurance ,tru/ ,fund "u section #ahag ( su* ,act 7#db ,u4,s4,c4 #acie;i7 & ! ,f$]al ,supplem5t>y ,insurance ,tru/ ,fund "u section #ahda ( su* ,act 7#db ,u4,s4,c4 #aciet71 9 su* proportion z ! ,secret>y may det]m9e1 (-- 7#a7 #abe1jjj1jjj to ! ,(fice ( ,m$ic>e ,he>+s & ,appeals2 & 7#b7 #b1jjj1jjj to ! ,dep>tm5tal ,appeals ,bo>d ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices4 ,am\nts transf]r$ "u ! prec$+ s5t5ce %all be 9 addition to any o!r am\nts t may be available = su* purposes & %all rema9 available until exp5d$4 7b7 ,,gao /udy & report 7#a7 ,/udy ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all conduct a /udy ( ! use ( ! am\nt made available to ! ,(fice ( ,m$ic>e ,he>+s & ,appeals "u subsection 7a7 to det]m9e :e!r ! availability ( su* am\nts l$ to any improvem5ts 9 ! ,m$ic>e appeals program1 su* z an increas$ numb] ( appeals process$ or a decrease 9 ! "t requir$ to process an appeal4 7#b7 ,report ,n lat] ?an ,decemb] #ca1 #bjah1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit a report to ,congress on ! /udy requir$ "u p>agraph 7#a71 toge!r ) recomm5dations = su* legislative & adm9i/rative actions z ! ,comptroll] ,g5]al det]m9es appropriate4 #c4 ,e/abli%m5t ( ,m$ic>e magi/rate review & revision ( am\nt 9 controv]sy ?re%olds 7a7 ,e/abli%m5t ( ,m$ic>e magi/rate program 7#a7 ,9 g5]al ,section #ahfi7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7b77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#d7 ,conduct ( reviews by ,m$ic>e magi/rates 7,a7 ,9 g5]al ,! ,secret>y %all e/abli% )9 ! ,(fice ( ,m$ic>e ,he>+s & ,appeals decision-mak+ (ficials to be kn[n z ,m$ic>e magi/rates4 7,b7 ,m$ic>e magi/rate def9$ ,= purposes ( ?is section1 ! t]m ,m$ic>e magi/rate means an attorney :o is lic5s$ by a ,/ate1 has exp]tise 9 ?is title 7includ+ regulations & policies promulgat$ !reund]71 meets su* o!r qualifications z ! ,secret>y %all require1 & :o p]=ms reviews & r5d]s decisions 9 appeals describ$ 9 p>agraph 7#a77;,e77i77,,ii74 7,c7 ,requirem5ts = reviews conduct$ by magi/rates ,! provisions ( ?is subsection & subsection 7d7 t gov]n he>+s & decisions by adm9i/rative law judges 7includ+ provisions relat$ to reviews ( decisions by adm9i/rative law judges by ! ,dep>tm5tal ,appeals ,bo>d ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices7 %all apply to reviews & decisions by ,m$ic>e magi/rates 9 ! same mann] & to ! same ext5t z su* provisions apply to he>+s & decisions by an adm9i/rative law judge4 ,! ,secret>y may e/abli% by regulation su* o!r requirem5ts & proc$ures z may be necess>y s t reviews by ,m$ic>e magi/rates are resolv$ fairly1 effici5tly1 & exp$iti\sly4 4 7#b7 ,con=m+ am5dm5t ,section #ahfi7;b77#a77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7b77#a77;,a77 is am5d$ by ins]t+ & p>agraph 7#d7 aft] subject to subp>agraphs 7,d7 & 7,e74 7b7 ,am\nt 9 controv]sy ?re%olds 7#a7 ,9 g5]al ,section #ahfi7;b77#a77;,e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7b77#a77;,e77 is am5d$-- 7,a7 by /rik+ clause 7i7 & ins]t+ ! foll[+3 7i7 ,9 g5]al ,except z o!rwise provid$ 9 ?is section1 subject to clause 7iii7-- 7,i7 a review by a ,m$ic>e magi/rate "u p>agraph 7#d71 or a he>+ by an adm9i/rative law judge "u ?is subsection or subsection 7d71 %all n be available to an individual if ! am\nt 9 controv]sy is less ?an #aej2 7,,ii7 a review by a ,m$ic>e magi/rate "u p>agraph 7#d7 %all be available to an individual if ! am\nt 9 controv]sy is equal to or great] ?an ! am\nt specifi$ 9 subclause 7,i7 b less ?an ! am\nt specifi$ 9 subclause 7,,iii72 & 7,,iii7 a he>+ by an adm9i/rative law judge %all be available to an individual "u ?is subsection or subsection 7d7 if ! am\nt 9 controv]sy is equal to or great] ?an #a1ejj4 2 7,b7 9 clause 7iii7-- 7i7 by /rik+ ,= reque/s = he>+s & ins]t+ ,= reque/s = ,m$ic>e magi/rate reviews1 he>+s12 7ii7 by /rik+ #bjjd & ins]t+ #bjag2 & 7iii7 by /rik+ #bjjc & ins]t+ #bjaf2 & 7,c7 by add+ at ! end ! foll[+ new clause3 7iv7 ,judicial review ,judicial review %all n be available to an individual "u ?is section if ! am\nt 9 controv]sy is less ?an ! am\nt specifi$ 9 clause 7i77,,iii74 4 7#b7 ,con=m+ am5dm5ts 7,a7 ,section #aaee ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;c-#d7 is am5d$-- 7i7 9 ! second s5t5ce1 by /rik+ #bjj or m & ins]t+ equal to or great] ?an ! am\nt specifi$ 9 section #ahfi7;b77#a77;,e77i77,,iii72 7ii7 9 ! f\r? s5t5ce1 by /rik+ #b1jjj or m & ins]t+ equal to or great] ?an ! am\nt specifi$ 9 section #ahfi7;b77#a77;,e77i77,,iii72 & 7iii7 by add+ at ! end ! foll[+ new s5t5ces3 ,:]e ! am\nt 9 controv]sy is equal to or great] ?an ! am\nt specifi$ 9 subclause 7,i7 ( section #ahfi7;b77#a77;,e77i7 b less ?an ! am\nt specifi$ 9 subclause 7,,iii7 ( su* section1 su* b5efici>y %all be entitl$ to a review by a ,m$ic>e magi/rate 9 accordance ) proc$ures e/abli%$ by ! ,secret>y pursuant to section #ahfi4 ,! provisions ( section #ahfi7;b77#a77;,e77iii7 %all apply ) respect to ! doll> am\nts ref]r$ to 9 ?is section 9 ! same mann] z !y apply to ! doll> am\nts specifi$ 9 section #ahfi7;b77#a77;,e77i744 7,b7 ,section #aheb7;g77#e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;g77#e77 is am5d$-- 7i7 9 ! fir/ s5t5ce1 by /rik+ #ajj or m & ins]t+ equal to or great] ?an ! am\nt specifi$ 9 section #ahfi7;b77#a77;,e77i77,,iii72 7ii7 9 ! second s5t5ce1 by /rik+ #a1jjj or m & ins]t+ equal to or great] ?an ! am\nt specifi$ 9 section #ahfi7;b77#a77;,e77i77,,iii72 7iii7 by ins]t+ aft] ! second s5t5ce ! foll[+ new s5t5ce3 ,if ! am\nt 9 controv]sy is equal to or great] ?an ! am\nt specifi$ 9 subclause 7,i7 ( section #ahfi7;b77#a77;,e77i7 b less ?an ! am\nt specifi$ 9 subclause 7,,iii7 ( su* section1 su* enrollee %all be entitl$ to review by a ,m$ic>e magi/rate 9 accordance ) proc$ures e/abli%$ by ! ,secret>y pursuant to section #ahfi42 & 7iv7 9 ! la/ s5t5ce1 by /rik+ ! fir/ #b s5t5ces (4 7,c7 ,section #ahgf7;c77#e77;,b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciemm7c77#e77;,b77 is am5d$-- 7i7 9 ! fir/ s5t5ce1 by /rik+ #ajj or m & ins]t+ equal to or great] ?an ! am\nt specifi$ 9 section #ahfi7;b77#a77;,e77i77,,iii72 7ii7 9 ! second s5t5ce1 by /rik+ #a1jjj or m & ins]t+ equal to or great] ?an ! am\nt specifi$ 9 section #ahfi7;b77#a77;,e77i77,,iii72 7iii7 by ins]t+ aft] ! second s5t5ce ! foll[+ new s5t5ce3 ,if ! am\nt 9 controv]sy is equal to or great] ?an ! am\nt specifi$ 9 subclause 7,i7 ( section #ahfi7;b77#a77;,e77i7 b less ?an ! am\nt specifi$ 9 subclause 7,,iii7 ( su* section1 su* memb] %all be entitl$ to review by a ,m$ic>e magi/rate 9 accordance ) proc$ures e/abli%$ by ! ,secret>y pursuant to section #ahfi42 & 7iv7 9 ! la/ s5t5ce1 by /rik+ ! fir/ #b s5t5ces (4 7c7 ,calculation ( am\nt 9 controv]sy = ! aggregation ( claims ,section #ahfi7;b77#a77;,e77ii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7b77#a77;,e77ii77 is am5d$-- 7#a7 by r$esignat+ subclauses 7,i7 & 7,,ii7 z items 7aa7 & 7bb71 respectively1 & ind5t+ appropriately2 7#b7 9 ! matt] prec$+ item 7aa71 z s r$esignat$1 by /rik+ if ! appeals involve & ins]t+ ! foll[+3 8if-- 7,i7 ! appeals involve-- 2 7#c7 9 item 7bb71 z s r$esignat$1 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 & 7#d7 by add+ at ! end ! foll[+ new subclause3 7,,ii7 all claims t an individual seeks to aggregate are includ$ 9 ! same reque/ = an aggregat$ appeal4 4 7d7 ,effective date ,! am5dm5ts made by ?is section %all take effect on ,janu>y #a1 #bjag4 #d4 ,rem&+ appeals to ! r$et]m9ation level ) ! introduction ( new evid5ce 7a7 ,9 g5]al ,section #ahfi7;b77#c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7b77#c77 is am5d$ by /rik+ ,a provid] ( s]vices & all t foll[s ?r\gh ! p]iod & ins]t+ ! foll[+ new subp>agraphs3 7,a7 ,rem& ^u submission ( new evid5ce 7i7 ,9 g5]al ,except z provid$ 9 subp>agraph 7,b71 :5 a p>ty to an appeal1 o!r ?an an individual entitl$ to1 or enroll$ =1 b5efits "u "p ,a or enroll$ "u "p ,b or ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices or its contractors1 introduces new evid5ce into ! adm9i/rative record at a reconsid]ation conduct$ by a qualifi$ indep5d5t contractor "u subsection 7c7 or at any subsequ5t1 high] level ( appeal1 ! appeal %all be rem&$ = a de novo r$et]m9ation "u subsection 7a77#c71 & any prior decisions 7o!r ?an ! initial det]m9ation made by ! ,secret>y pursuant to subsection 7a77#a77 on ?is appeal %all be vacat$4 7ii7 ,requirem5ts ,= purposes ( clause 7i71 except to ! ext5t o!rwise provid$ by ! ,secret>y 9 regulations1 ! provisions t apply to r$et]m9ations "u subsection 7a7 & ?is subsection %all apply to r$et]m9ations ( appeals t are rem&$4 7,b7 ,exceptions ,! provisions ( subp>agraph 7,a7 %all n apply 9 in/ances :]e an adjudicator det]m9es t introduction ( new evid5ce is ju/ifi$ due to-- 7i7 an inadv]t5t omission or errone\s decision by a l[]-level adjudicator to omit ! evid5ce f ! adm9i/rative record :5 t evid5ce 0 timely submitt$ to ! l[]-level adjudicator by a p>ty to ! appeal2 7ii7 a decision by a l[]-level adjudicator to issue an unfavorable decision bas$ on new or diff]5t gr\nds ?an 7 previ\sly adjudicat$2 or 7iii7 su* o!r circum/ances = good cause z ! ,secret>y may e/abli%4 7,c7 ,no appeal ,a decision to rem& an appeal "u ?is p>agraph %all n be subject to appeal4 4 7b7 ,effective date ,! am5dm5ts made by ?is section %all take effect on ,janu>y #a1 #bjag4 #e4 ,exp$it$ access to appeals 7a7 ,9 g5]al ,section #ahfi7;b77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7b77#a77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,h7 ,exp$it$ access to appeals 7i7 ,decision on ! record ,n lat] ?an ,janu>y #a1 #bjag1 ! ,secret>y %all e/abli% by regulation & implem5t a process au?oriz+ an adm9i/rative law judge review+ a decision pursuant to ?is subsection or subsection 7d7 to issue a decision on ! record 9 cases :]e1 bas$ on ! evid5ce ( record1 !re are no mat]ial issues ( fact 9 dispute & ! adm9i/rative law judge det]m9es t !re is a b9d+ au?ority t controls ! decision 9 ! matt] "u review4 7ii7 ,exp$it$ access to judicial review n reque/$ by appellant ,! ,secret>y %all by regulation e/abli% a process au?oriz+ an adm9i/rative law judge review+ a decision pursuant to ?is subsection or subsection 7d7 to c]tify ! appeal = exp$it$ access to judicial review :]e-- 7,i7 ! appellant does n reque/ exp$it$ access to judicial review pursuant to p>agraph 7#b72 7,,ii7 !re are no mat]ial issues ( fact 9 dispute2 & 7,,iii7 nei!r ! adm9i/rative law judge nor ! ,dep>tm5tal ,appeals ,bo>d has au?ority to decide ! que/ions ( law or regulation relevant to ! matt]s 9 controv]sy4 7iii7 ,application ( he>+ rules to decisions on ! record ,! provisions ( subsection 7d7 t gov]n he>+s by adm9i/rative law judges %all apply to a decision issu$ by an adm9i/rative law judge )\t a he>+ pursuant to clause 7i7 9 ! same mann] & to ! same ext5t z su* provisions apply to a he>+ by an adm9i/rative law judge4 7iv7 ,effect ( c]tification = judicial review ,not)/&+ subsection 7d77#b71 a decision to c]tify an appeal pursuant to clause 7ii7 %all n be subject to fur!r review by ! ,secret>y & %all be deem$ a f9al decision by ! ,secret>y z provid$ 9 section #bje7;g7 7z appli$ to ?is section7 = purposes ( det]m9+ an individual's entitlem5t to judicial review4 4 7b7 ,con=m+ am5dm5ts 7#a7 ,section #aaee ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acbj;c-#d71 z am5d$ by section #c7;b77#b77;,a71 is am5d$-- 7,a7 9 ! second s5t5ce1 by /rik+ ,:]e & ins]t+ ,subject to ! succe$+ s5t5ces ( ?is section1 :]e2 & 7,b7 by add+ at ! end ! foll[+ new s5t5ce3 ,! provisions ( subp>agraph 7,h7 ( section #ahfi7;b77#a7 %all apply ) respect to decisions by an adm9i/rative law judge "u ?is section 9 ! same mann] z !y apply to decisions by an adm9i/rative law judge "u su* subp>agraph 7,h744 7#b7 ,section #aheb7;g77#e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bb7;g77#e771 z am5d$ by section #c7;b77#b77;,b71 is am5d$-- 7,a7 9 ! fir/ s5t5ce1 by /rik+ ,an enrollee & ins]t+ ,subject to ! succe$+ s5t5ces ( ?is p>agraph1 an enrollee2 & 7,b7 by add+ at ! end ! foll[+ new s5t5ce3 ,! provisions ( subp>agraph 7,h7 ( section #ahfi7;b77#a7 %all apply ) respect to decisions by an adm9i/rative law judge "u ?is p>agraph 9 ! same mann] z !y apply to decisions by an adm9i/rative law judge "u su* subp>agraph 7,h744 7#c7 ,section #ahfi7;b77#a77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7b77#a77;,a771 z am5d$ by section #c7;a77#b71 is am5d$ by /rik+ subp>agraphs 7,d7 & 7,e7 & ins]t+ subp>agraphs 7,d71 7,e71 & 7,h74 7#d7 ,section #ahgf7;c77#e77;,b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciemm7c77#e77;,b771 z am5d$ by section #c7;b77#b77;,c71 is am5d$-- 7,a7 9 ! fir/ s5t5ce1 by /rik+ ,a memb] & ins]t+ ,subject to ! succe$+ s5t5ces ( ?is subp>agraph1 a memb]2 & 7,b7 by add+ at ! end ! foll[+ new s5t5ce3 ,! provisions ( subp>agraph 7,h7 ( section #ahfi7;b77#a7 %all apply ) respect to decisions by an adm9i/rative law judge "u ?is subp>agraph 9 ! same mann] z !y apply to decisions by an adm9i/rative law judge "u su* subp>agraph 7,h744 7c7 ,effective date ,! am5dm5ts made by subsections 7a7 & 7b7 %all take effect on ! date ( ! enactm5t ( ?is ,act & %all apply to cases t are p5d+ z ( su* date4 #f4 ,au?ority to use sampl+ & extrapolation me?odologies & to consolidate appeals = adm9i/rative effici5cy 7a7 ,9 g5]al ,section #ahfi ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7j7 ,au?orities ,to promote adm9i/rative effici5cies 7#a7 ,au?ority to consolidate appeals 7,a7 ,9 g5]al ,any individual or entity conduct+ r$et]m9ations1 reconsid]ations1 reviews1 or he>+s "u subsection 7a77#c71 7b71 7c71 or 7d7 79 ?is section1 ref]r$ to z an adjudicator7 may consolidate p5d+ reque/s = review into a s+le action1 & may issue a s+le decision1 or sep>ate decisions1 ) respect to su* review reque/s-- 7i7 if su* reque/s involve "o or m common que/ions ( fact or law = simil> claims submitt$ by ! same individual or entity2 7ii7 if su* reque/s involve claims t 7 includ$ )9 a /ati/ical sample dur+ ! initial det]m9ation or any previ\s level ( appeal2 7iii7 if ! appellant reque/s aggregation ( two or m claims "u subsection 7b77#a77;,e77ii72 or 7iv7 9 any o!r case 9 :i* ! adjudicator det]m9es t consolidation w\ld promote adm9i/rative effici5cy1 consi/5t ) su* /&>ds z ! ,secret>y %all e/abli% by regulation4 7,b7 ,deadl9es ,! ,secret>y may e/abli% ! applicable timeframe = reque/+ consolidations & = issu+ decisions on appeals t h be5 consolidat$4 7#b7 ,requirem5ts = claims t 7 includ$ 9 an extrapolat$ ov]paym5t or previ\sly consolidat$ ,an individual or entity reque/+ a r$et]m9ation1 reconsid]ation1 review or he>+ "u subsection 7a77#c71 7b71 7c71 or 7d7 ) respect to two or m claims t 7 includ$ 9 an extrapolat$ ov]paym5t1 or claims t 7 consolidat$ into a s+le appeal at a l[]-level adjudication "u ?is section1 mu/ submit a s+le reque/ = review or he>+ ) respect to su* claims 9 ord] to be entitl$ to a review or he>+4 7#c7 ,au?ority to use /ati/ical sampl+ & extrapolation me?odologies 9 adjudications ,) ! cons5t ( ! appellant1 an adjudicator may use /ati/ical sampl+ & extrapolation me?odologies 9 rea*+ a decision ) respect to a claim or claims = b5efits = items or s]vices furni%$ "u "p ,a or ,b4 ,:5 an appeal involves a decision t 0 bas$ on a /ati/ical sample at ! l[] level1 ! adjudicator's decision %all be bas$ on ! same /ati/ical sample4 4 7b7 ,effective date ,! am5dm5ts made by ?is section %all apply to reque/s = review t are p5d+ at any level ( appeal z ( ! date ( ! enactm5t ( ?is ,act & to ^? fil$ aft] su* date4 #g4 ,id5tification & ref]ral ( fraud ,n lat] ?an ,janu>y #a1 #bjag1 ! ,secret>y ( ,heal? & ,human ,s]vices1 9 consultation ) ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices & ! ,attorney ,g5]al ( ! ,unit$ ,/ates1 %all e/abli% & implem5t a process "u :i* ! ,(fice ( ,m$ic>e ,he>+s & ,appeals & ! ,dep>tm5tal ,appeals ,bo>d ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices %all ref] cases 9 :i* !re is a cr$ible suspicion ( fraudul5t activity to appropriate law en=cem5t ag5cies & to ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices4 #h4 ,/udy to assess he>+ p>ticipation 7a7 ,/udy ,n lat] ?an ,janu>y #a1 #bjag1 ! ,secret>y ( ,heal? & ,human ,s]vices %all conduct a /udy to det]m9e :e!r x w\ld be feasible to increase ! p>ticipation1 ) respect to he>+s conduct$ by ! ,(fice ( ,m$ic>e ,he>+s & ,appeals1 (-- 7#a7 ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices2 7#b7 entities s]v+ z qualifi$ indep5d5t contractors "u section #ahfi7;c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7c772 7#c7 entities s]v+ z m$ic>e adm9i/rative contractors "u section #ahgd;,a ( su* ,act 7#db ,u4,s4,c4 #aciekk-#a72 7#d7 entities s]vices z recov]y audit contractors "u section #ahic7;h7 ( su* ,act 7#db ,u4,s4,c4 #acie;ddd7h772 & 7#e7 o!r ,m$ic>e claims review entities det]m9$ appropriate by ! ,secret>y4 7b7 ,report ,n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices %all publi% a report conta9+ ! results ( ! /udy requir$ "u subsection 7a7 on ! ,int]net website ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices4 #i4 ,improvem5ts to ! ,(fice ( ,m$ic>e ,he>+s & ,appeals 7a7 ,tra9+ = ,a,l,js & ,m$ic>e magi/rates ,section #ahfi7;e77#c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7e77#c77 is am5d$-- 7#a7 9 ! p>agraph head+1 by /rik+ & adm9i/rative law judges & ins]t+ 1 adm9i/rative law judges1 & ,m$ic>e magi/rates2 ,annual tra9+ = adm9i/rative law judges & ,m$ic>e magi/rates2 7#b7 by /rik+ ,! ,secret>y & ins]t+ ! foll[+3 7,a7 ,cont9u+ education requirem5t ,! ,secret>y 2 7#c7 by ins]t+ &1 beg9n+ 9 #bjag1 to ,m$ic>e magi/rates aft] adm9i/rative law judges ! fir/ place x appe>s2 7#d7 by /rik+ & adm9i/rative law judges & ins]t+ 1 adm9i/rative law judges1 & ,m$ic>e magi/rates2 & 7#e7 by add+ at ! end ! foll[+ new subp>agraph3 7,b7 ,annual tra9+ ,beg9n+ ) #bjag1 ea* ye> ! ,secret>y %all provide to ea* adm9i/rative law judge & ,m$ic>e magi/rate )9 ! ,(fice ( ,m$ic>e ,he>+s & ,appeals tra9+ on ,m$ic>e policies1 includ+ any policies t 7 *ang$ or in/itut$ 9 ! previ\s ye>4 4 7b7 ,treatm5t ( ,,qic decisions ,section #ahfi7;d77#d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7d77#d77 is am5d$-- 7#a7 9 subp>agraph 7,b71 by /rik+ & at ! end2 7#b7 9 subp>agraph 7,c71 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 & 7#c7 by add+ at ! end ! foll[+ new subp>agraph3 7,d7 9 ! case ( a review conduct$ on or aft] ,janu>y #a1 #bjag1 ( a decision by a qualifi$ indep5d5t contractor 9 :i* ! adm9i/rative law judge rea*es a diff]5t decision ?an ! qualifi$ indep5d5t contractor1 ! reasons :y ! decision ( ! adm9i/rative law judge diff]s f ! decision ( ! qualifi$ indep5d5t contractor4 4 7c7 ,publication ( appeals in=mation ,section #ahfi7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7e77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#e7 ,publication ( appeals in=mation ,n lat] ?an ,janu>y #a1 #bjag1 & annually !reaft]1 ! ,secret>y ( ,heal? & ,human ,s]vices %all publi% & ma9ta9 on ! ,int]net website ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices ! foll[+ in=mation1 :i* may be effectuat$ ?r\gh ! use ( /ati/ical sampl+1 reg>d+ appeals he>d by ! ,(fice ( ,m$ic>e ,he>+s & ,appeals = ea* fiscal ye>3 7,a7 ,! p]c5tage ( appeals t receiv$ fully favorable1 p>tially favorable1 & unfavorable decisions4 7,b7 ,= ea* adm9i/rative law judge1 ! p]c5tage ( appeals t receiv$ fully favorable1 p>tially favorable1 & unfavorable decisions4 7,c7 ,= ea* type ( s]vice1 ! p]c5tage ( appeals t receiv$ fully favorable1 p>tially favorable1 & unfavorable decisions4 7,d7 ,! av]age l5g? ( "t elaps$ betwe5 ! initial reque/ = review & a f9al decision4 7,e7 ,su* o!r in=mation z ! ,secret>y det]m9es necess>y to ensure great] transp>5cy = ! ,(fice ( ,m$ic>e ,he>+s & ,appeals4 4 7d7 ,,gao review ( consi/5cy ( ,,omha decisions 7#a7 ,/udy 7,a7 ,9 g5]al ,! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all conduct a /udy ( decisions r5d]$ by ! ,(fice ( ,m$ic>e ,he>+s & ,appeals to det]m9e ! frequ5cy ) :i* decisions by adm9i/rative law judges or ,m$ic>e magi/rates-- 7i7 div]ge f ! int]pretation ( ,m$ic>e policy & program in/ruction ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices2 7ii7 demon/rate significant v>iation 9 ! int]pretation ( simil> ,m$ic>e policies or in/ructions2 & 7iii7 fail to apply applicable ,m$ic>e law1 regulation1 policy1 or in/ruction4 7,b7 ,me?odology ,9 conduct+ ! /udy requir$ "u ?is p>agraph1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all focus on decisions r5d]$ by ! ,(fice ( ,m$ic>e ,he>+s & ,appeals n less ?an #a ye> aft] ! date ( ! enactm5t ( ?is ,act &1 if ! ,comptroll] s *ooses1 may use sampl+ to id5tify decisions to evaluate4 7#b7 ,report ,n lat] ?an ,janu>y #a1 #bjah1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates %all submit a report to ,congress on ! /udy requir$ "u p>agraph 7#a71 toge!r ) recomm5dations = su* legislative & adm9i/rative actions z ! ,comptroll] ,g5]al det]m9es appropriate4 7e7 ,id5tification ( inconsi/5t int]pretations ( policies across review entities ,n lat] ?an ,janu>y #a1 #bjag1 ! ,secret>y ( ,heal? & ,human ,s]vices %all e/abli% & implem5t a process = id5tify+ policies or cov]age det]m9ations relat+ to title ,,xviii ( ! ,social ,security ,act t are mo/ frequ5tly int]pret$ & appli$ diff]5tly by review entities1 ,m$ic>e magi/rates1 adm9i/rative law judges1 or ! ,dep>tm5t ,appeals ,bo>d ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices4 ,z a "p ( su* process1 ! ,secret>y %all1 :]e appropriate1 issue guidance or take o!r adm9i/rative action to cl>ify h[ a policy or cov]age decision %\ld be int]pret$ 9 ord] to prev5t future conflict+ int]pretations4 7f7 ,/udy & report on adm9i/rative law judge specialization 7#a7 ,/udy ,! ,secret>y ( ,heal? & ,human ,s]vices %all conduct a /udy to det]m9e if ! specialization ( adm9i/rative law judges )9 ! ,(fice ( ,m$ic>e ,he>+s & ,appeals by type ( appeal w\ld lead to m consi/5t decisions by adm9i/rative law judges det]m9+ cases ) simil> facts4 7#b7 ,report ,n lat] ?an ,janu>y #a1 #bjah1 ! ,secret>y ( ,heal? & ,human s]vices %all submit to ,congress a report conta9+ ! results ( ! /udy requir$ "u p>agraph 7#a71 toge!r ) recomm5dations = su* legislative & adm9i/rative action z ! ,secret>y det]m9es appropriate4 7g7 ,alt]native dispute resolution 7#a7 ,9 g5]al ,section #ahfi7;b7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7b771 z am5d$ by section #c7;a71 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#e7 ,alt]native dispute resolution 7,a7 ,9 g5]al 7i7 ,r$et]m9ation & reconsid]ation ,,adr process ,! ,secret>y %all e/abli% "o or m alt]native dispute resolution processes :]eby1 at ! ,secret>y's discretion1 an individual or entity entitl$ to a r$et]m9ation "u subsection 7a77#c7 by a m$ic>e adm9i/rative contractor or a reconsid]ation "u subsection 7c7 by a qualifi$ indep5d5t contractor may h ! option to ent] into alt]native dispute resolution ) ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices1 consi/5t ) ! foll[+3 7,i7 ,dur+ ! alt]native dispute resolution process1 ! reque/ = review ) respect to ! claims cov]$ by ! alt]native dispute resolution %all be susp5d$4 7,,ii7 ,9 ! ev5t t an alt]native dispute resolution does n result 9 a settlem5t1 ! reque/ = review ) respect to ! claims cov]$ by ! alt]native dispute resolution %all resume "u subsection 7a77#c7 or subsection 7c71 z applicable4 7ii7 ,he>+ & review m$iation ,! ,secret>y %all e/abli% an alt]native dispute resolution process :]eby1 at ! ,secret>y's discretion1 an individual or entity entitl$ to a review or he>+ on a decision ( a qualifi$ indep5d5t contractor by a ,m$ic>e magi/rate or an adm9i/rative law judge may h ! option to ent] into an alt]native dispute resolution process m$iat$ by /aff memb]s ( ! ,(fice ( ,m$ic>e ,he>+s & ,appeals select$ = ! purpose ( m$iat+ alt]native dispute resolutions "u ?is p>agraph4 7,b7 ,effect ( alt]native dispute resolution 7i7 ,9 g5]al ,z "p ( any alt]native dispute resolution settlem5t "u ?is p>agraph1 an appellant %all be requir$ to-- 7,i7 =ego ! "r to su* r$et]m9ation1 reconsid]ation1 review1 or he>+1 z applicable2 & 7,,ii7 )draw all reque/s = review ) respect to ! claims cov]$ by ! settlem5t4 7ii7 ,no judicial review ,!re %all be no adm9i/rative or judicial review "u section #ahfi1 #ahgh1 or o!rwise ( ! alt]native dispute resolution settlem5t & ! claims cov]$ by ! settlem5t4 7,c7 ,coord9ation ) law en=cem5t & ,,cms ,! ,secret>y %all e/abli% a process "u :i* ! (fic]s responsible = conduct+ an alt]native dispute resolution process %all coord9ate ) appropriate law en=cem5t ag5cies & ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices to avoid ! inadv]t5t settlem5t ( cases t involve fraud or o!r crim9al activity4 7,d7 ,no entitlem5t to alt]native dispute resolution ,no?+ 9 ?is p>agraph %all be con/ru$ z creat+ an entitlem5t to alt]native dispute resolution4 4 7#b7 ,con=m+ am5dm5ts 7,a7 ,section #ahfi7;a77#c77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7a77#c77;,a77 is am5d$ by ins]t+ 81 subject to subsection 7b77#e710 aft] regulations %all4 7,b7 ,section #ahfi7;b77#a77;,a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ff7b77#a77;,a771 z am5d$ by section #c7;a77#b71 is am5d$-- 7i7 by ins]t+ & p>agraph 7#e7 aft] 8,subject to subp>agraph 7,d702 & 7ii7 by /rik+ & p>agraph 7#d7 & ins]t+ & p>agraphs 7#d7 & 7#e74 #aj4 ,review program improvem5ts 7a7 ,9 g5]al ,section #ahic ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7 is am5d$-- 7#a7 9 subsection 7b71 by add+ at ! end ! foll[+ new p>agraph3 7#g7 ,! review program improvem5ts describ$ 9 subsection 7j74 2 7#b7 by r$esignat+ subsection 7i7 z subsection 7j72 & 7#c7 by ins]t+ aft] subsection 7h7 ! foll[+ new subsection3 7i7 ,review program improvem5ts 7#a7 ,9 g5]al 4 7,a7 ,guidel9es 7i7 ,9 g5]al ,to ensure uni=mity & consi/5cy 9 initial det]m9ations & appeals decisions relat+ to ! appropriat5ess ( paym5t ) respect to items or s]vices furni%$ "u ?is title1 ! ,secret>y %all ensure t claim review guidel9es are e/abli%$ = review+ claims = paym5t submitt$ by provid]s ( s]vices & suppli]s4 7ii7 ,requirem5ts ,prior to ! implem5tation ( ! claim review guidel9es describ$ 9 subp>agraph 7,a77i71 ! ,secret>y %all-- 7,i7 approve ! claim review guidel9es2 7,,ii7 make ! claim review guidel9es publicly available z describ$ 9 subp>agraph 7,b72 7,,iii7 ensure t review contractors apply ! claim review guidel9es consi/5tly1 z appropriate2 & 7,,iv7 ensure t ,m$ic>e magi/rates1 adm9i/rative law judges1 & ! ,dep>tm5tal ,appeals ,bo>d are tra9$ 9 ! application ( ! claim review guidel9es4 7iii7 ,transition p]iod ,! ,secret>y may provide = or e/abli% "o or m transition p]iods1 dur+ :i* ! use ( exi/+ claim review guidel9es = review+ claims submitt$ by provid]s ( s]vices & suppli]s %all be p]mitt$ to cont9ue until su* "t z ! ,secret>y is able to review & approve ! claim review guidel9es e/abli%$ "u ?is subp>agraph4 7,b7 ,transp>5cy 7i7 ,9 g5]al ,! ,secret>y %all ensure t ! in=mation describ$ 9 clause 7iii7-- 7,i7 is publi%$ on ! ,int]net website ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices = n less ?an #cj days prior to its implem5tation2 7,,ii7 rema9s available on su* ,int]net website aft] su* publication2 & 7,,iii7 is updat$ at lea/ annually4 7ii7 ,exp$it$ process ,! ,secret>y ( ,heal? & ,human ,s]vices may exp$ite ! process describ$ 9 clause 7i7 = claims review guidel9es t are expect$ to impact ! improp] paym5t rate1 frequ5cy ( d5ials ( paym5t1 or co/s to ! ,m$ic>e program4 7iii7 ,in=mation describ$ ,! in=mation describ$ 9 ?is clause is ! foll[+3 7,i7 ,subject to clause 7ii7 & subp>agraph 7,a71 any new claim review guidel9e approv$ = use "u ?is p>agraph4 7,,ii7 ,any updates or revisions to exi/+ claim review guidel9es4 7,c7 ,limitation ,no?+ 9 ?is section is int5d$ to-- 7i7 del9eate sample size or h[ claims are to be select$ = review2 7ii7 require ! publication ( algori?ms or me?odologies us$ = claim selection2 or 7iii7 require ! publication ( in=mation t c\ld promote fraud or pot5tial gam+4 7,d7 ,review contractor def9$ ,9 ?is subsection1 ! t]m review contractor means-- 7i7 a m$ic>e adm9i/rative contractor 7z def9$ 9 section #ahgd;,a7a77#c77;,a77 ) a contract to conduct prepaym5t or po/-paym5t reviews ( claims = paym5t by provid]s ( s]vices or suppli]s2 7ii7 a recov]y audit contractor ) a contract "u subsection 7h72 or 7iii7 any o!r contractor ! ,secret>y det]m9es appropriate4 7#b7 ,program integrity initiatives ,to improve exi/+ & future ,m$ic>e program integrity initiatives1 & to limit unnecess>y burd5s on provid]s ( s]vices & suppli]s1 ! ,secret>y %all designate a po9t ( contact to ov]see & und]take ! foll[+3 7,a7 ,develop a compreh5sive /rategy = claim review det]m9ations made on a prepaym5t1 po/-paym5t1 or prior-au?orization basis t-- 7i7 focuses on id5tify+ & r$uc+ ^? claim errors t h ! l>ge/ impact on ! improp] paym5t rate1 pose ! greate/ risk to ! ,f$]al ,hospital ,insurance ,tru/ ,fund "u section #ahag ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;i7 or ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund "u section #ahda ( su* ,act 7#db ,u4,s4,c4 #aciet71 or are likely to negatively affect quality ( c>e2 7ii7 r$uces unnecess>y burd5 on provid]s ( s]vices & suppli]s & m9imizes any negative effects on ,m$ic>e b5efici>ies2 & 7iii7 utilizes data & o!r s\rces1 includ+ claims data1 improp] paym5t rate data1 & reports f ! ,(fice ( ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 ! ,g5]al ,acc\ntability ,(fice1 ! ,m$ic>e ,paym5t ,advisory ,commission1 & ! m$ia4 7,b7 ,develop me?ods to ensure1 us+ all available data1 t review contractors d n unnecess>ily conduct duplicate reviews ( specific individual claims4 7,c7 ,to ! ext5t possible giv5 ! specific mission ( ea* entity t has contract$ ) ! ,secret>y1 "w ) all review contractors to develop a uni=m1 consi/5t1 & transp>5t review process to r$uce ! burd5 on provid]s ( s]vices & suppli]s to ! greate/ ext5t possible1 includ+ a uni=m approa* = su* entities to notify p>ties ( p5d+ reviews & to reque/ m$ical docum5tation1 improv$ communication ) provid]s ( s]vices & suppli]s1 bett] ref9em5t ( audits to t>get claims t are at ! highe/ risk = improp] paym5ts or o!r errors1 & any o!r areas 9 :i* ! ,secret>y det]m9es t ! burd5 on provid]s ( s]vices & suppli]s may be decreas$4 7,d7 ,id5tify local cov]age det]m9ations1 national cov]age det]m9ations1 regulations1 & program in/ructions issu$ by ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices = ! ,m$ic>e program t ne$ updat+ or t inappropriately conflict ) o!r ,m$ic>e policies & make modifications :]e appropriate1 &1 if necess>y1 e/abli% new policies or claim review guidel9es ) input f /akehold]s z appropriate4 7,e7 ,publi% on ! ,int]net website ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices ! volume & type ( prepaym5t & po/-paym5t claim reviews p]=m$ by m$ic>e adm9i/rative contractors "u section #ahgd;,a ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciekk-#a7 & recov]y audit contractors "u section #ahic7;h7 ( su* ,act 7#db ,u4,s4,c4 #acie;ddd7h774 7,f7 ,coord9ate ) ! ,(fice ( ,m$ic>e ,he>+s & ,appeals & ! ,dep>tm5tal ,appeals ,bo>d ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices to ensure t ! improv$ claim review guidel9es & evid5ti>y /&>ds e/abli%$ by ! provisions (1 & ! am5dm5ts made by1 ?is ,act1 su* z ! decision to rem& an appeal1 are prop]ly implem5t$4 7,g7 ,ensure t provid]s ( s]vices & suppli]s subject to po/-paym5t review by a m$ic>e adm9i/rative contractor are grant$ a discussion p]iod ) ! contractor ( at lea/ #cj days f ! lett] f ! contractor reg>d+ ! result ( ! review4 7,h7 ,develop qualification /&>ds = review contractors t require prepaym5t & po/-paym5t reviews ( claims = paym5t submitt$ by provid]s ( s]vices or suppli]s to be conduct$ or approv$ by m$ical doctors ) k ( relevant ,m$ic>e laws1 regulations1 & program in/ruction1 z appropriate4 7,i7 ,v]ify1 ?r\gh ! use ( sampl+ if ! ,secret>y s *ooses1 t decisions by review contractors are consi/5t ) ,m$ic>e laws1 regulations1 & program in/ruction 7tak+ into acc\nt geographical v>iations t are a result ( local cov]age det]m9ations74 7,j7 ,det]m9e :e!r additional punitive actions aga9/ ineffective review contractors c\ld be tak5 & :at1 if any1 f9ancial inc5tives or dis9c5tives c\ld be us$ to promote ! accuracy ( a review contractor's reviews4 7#c7 ,m$ic>e provid] claim audit ,int]net portal 7,a7 ,9 g5]al ,! ,secret>y %all e/abli% a secure1 ,int]net-bas$ sy/em 7:i* may be bas$ on ! exi/+ database sy/em ( claims "u review us$ by review contractors or a simil> exi/+ sy/em7 ?r\gh :i* a provid] ( s]vices1 a suppli]1 or o!r appropriate entity may track ! /atus ( any claim = paym5t submitt$ by su* provid] or suppli] t is be+ audit$ or process$ z an appeal by-- 7i7 a m$ic>e adm9i/rative contractor "u section #ahgd;,a2 or 7ii7 a qualifi$ indep5d5t contractor1 ,m$ic>e magi/rate1 adm9i/rative law judge1 or ! ,dep>tm5tal ,appeals ,bo>d ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices "u section #ahfi4 7,b7 ,fraud prev5tion ,! ,secret>y %all ensure t ! sy/em e/abli%$ "u p>agraph 7#a7 does n imp$e any ongo+ inve/igations ( pot5tial fraud4 7,c7 ,progress report ,n lat] ?an #ahj days aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y %all submit a report to ,congress describ+ ! plan to e/abli% & op]ate ! sy/em describ$ 9 p>agraph 7#a74 4 7b7 ,annual ,,rac report ,section #ahic7;h77#h7 is am5d$ by ins]t+ 1 &1 ) respect to reports submitt$ aft] ! date ( ! enactm5t ( ! ,audit ,appeals ,fairness1 ,integrity1 & ,re=ms 9 ,m$ic>e ,act ( #bjae1 ! numb] ( claims correct$ 9 ! discussion p]iod1 ! p]c5tage ( appeals ( det]m9ations by recov]y audit contractors t 7 ultimately successful1 a c>eful description ( ! d5om9ator ( total audits & appeals 7giv5 ! likelihood t _m appeals 9 a giv5 ye> w n h a decision 9 t ye>71 & sep>ate reports on complex ,m$ic>e "p ,a1 complex ,m$ic>e "p ,b1 semiautomat$1 & automat$ reviews be=e ! p]iod at ! end4 7c7 ,indep5d5ce ( adjudicators ,no?+ 9 ?is section or ! am5dm5ts made !reby %all be con/ru$ z au?oriz+ ! ,secret>y to limit ! au?ority or decisional indep5d5ce ( ,m$ic>e magi/rates1 adm9i/rative law judges1 or ! ,dep>tm5tal ,appeals ,bo>d ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices4 #aa4 ,creation ( ,m$ic>e ,provid] & ,suppli] ,ombudsman = ,reviews & ,appeals ,section #ahjh ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;b-#i7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7d7 ,m$ic>e ,reviews & ,appeals ,ombudsman 7#a7 ,9 g5]al ,n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is subsection1 ! ,secret>y %all appo9t )9 ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices a ,m$ic>e ,reviews & ,appeals ,ombudsman4 7#b7 ,duties ,! ,m$ic>e ,reviews & ,appeals ,ombudsman %all-- 7,a7 id5tify1 inve/igate1 & assi/ 9 ! resolution ( compla9ts & inquiries relat$ to ! ,m$ic>e audits & appeals process f provid]s ( s]vices or suppli]s ) respect to b5efits "u "p ,a or ,b2 7,b7 id5tify tr5ds 9 compla9ts & inquiries reg>d+ ! curr5t ,m$ic>e review & appeals sy/ems to provide recomm5dations = improvem5ts to ! ,secret>y t w\ld improve ! efficacy & effici5cy ( claim review & appeals sy/ems1 z well z communication to b5efici>ies1 provid]s ( s]vices1 & suppli]s2 7,c7 design a sy/em by :i* to objectively measure & evaluate review] responsiv5ess to address+ inquiries f provid]s ( s]vices & suppli]s & inquiries f ! ,ombudsman2 7,d7 provide adm9i/rative & te*nical assi/ance to appellants & ^? consid]+ an appeal2 7,e7 publi% data reg>d+ ! numb] ( review det]m9ations appeal$1 ea* appeal's outcome1 & aggregate appeal /ati/ics-- 7i7 = ea* m$ic>e adm9i/rative contractor conduct+ r$et]m9ations "u section #ahfi7;a77#c72 7ii7 = ea* qualifi$ indep5d5t contractor conduct+ reconsid]ations "u section #ahfi7;c72 7iii7 = ea* recov]y audit contractor conduct+ reviews "u section #ahic7;h72 7iv7 by type ( provid] ( s]vices2 & 7v7 by type ( suppli]2 7,f7 assi/ 9 education & tra9+ ef=ts = provid]s ( s]vices1 suppli]s1 & review contractors 7z def9$ 9 section #ahic7;i77#a77;,d772 7,g7 communicate ) ! ,m$ic>e ,b5efici>y ,ombudsman to assi/ ) ! id5tification1 inve/igation1 & resolution ( b5efici>y-relat$ compla9ts1 includ+ ^? t ov]lap ) reque/s = review & appeals submitt$ by provid]s ( s]vices or suppli]s2 & 7,h7 p]=m su* o!r duties z det]m9$ appropriate by ! ,secret>y4 4 #ab4 ,limit+ ! audit & recov]y p]iod = pati5t /atus reviews 7a7 ,9 g5]al ,section #ahic7;h77#d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h77#d7 is am5d$-- 7#a7 by r$esignat+ subp>agraphs 7,a7 & 7,b7 z clauses 7i7 & 7ii71 respectively1 & mov+ su* clauses #b ems to ! "r2 7#b7 by /rik+ ,ea* su* & ins]t+ ! foll[+3 7,a7 ,9 g5]al ,except z provid$ 9 subp>agraph 7,b71 ea* su* 2 & 7#c7 by add+ at ! end ! foll[+ new subp>agraph3 7,b7 ,limitation 7i7 ,9 g5]al ,) respect to ! classification ( an individual entitl$ to1 or enroll$ =1 b5efits "u "p ,a or enroll$ "u "p ,b1 or bo?1 z an inpati5t or an outpati5t = purposes ( hospital claims = paym5t = items or s]vices furni%$ to su* individual "u ?is title1 su* contracts %all provide t a recov]y audit contractor %all only s5d additional docum5tation reque/s relat$ to ! appropriat5ess ( su* classification 9 ! fir/ #f mon?s aft] ! date on :i* su* items or s]vices 7 furni%$4 7ii7 ,exception ,! limitation describ$ 9 clause 7i7 %all n apply :]e a claim = paym5t is submitt$ m ?an #c mon?s aft] ! date on :i* su* items or s]vices 7 furni%$4 4 7b7 ,/udy on %ort5+ ! audit & recov]y p]iod = o!r reviews 7#a7 ,/udy ,! ,secret>y ( ,heal? & ,human ,s]vices %all conduct a /udy to assess-- 7,a7 ! pot5tial burd5 on provid]s ( s]vices 7z def9$ 9 subsection 7u7 ( section #ahfa ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciex77 & suppli]s 7z def9$ 9 subsection 7d7 ( su* section #ahfa7 "u ! ,m$ic>e program ( ! audit & recov]y p]iod applicable to audit & recov]y activities conduct$ by recov]y audit contractors "u section #ahic7;h77#d7 ( su* ,act 7#db ,u4,s4,c4 #acie;ddd7h77#d772 & 7,b7 ! impact ( %ort5+ su* p]iod ) respect to diff]5t types ( reviews4 7#b7 ,report ,n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices %all publi% a report conta9+ ! results ( ! /udy requir$ "u p>agraph 7#a7 on ! ,int]net website ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices4 7c7 ,au?ority ,to implem5t %ort] audit & recov]y p]iod ,section #ahic7;h77#d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h77#d771 z am5d$ by subsection 7a71 is fur!r am5d$-- 7#a7 9 subp>agraph 7,a71 by /rik+ subp>agraph 7,b7 & ins]t+ subp>agraphs 7,b7 & 7,c72 & 7#b7 by add+ at ! end ! foll[+ new subp>agraph3 7,c7 ,au?ority to implem5t %ort] audit & recov]y p]iod ,not)/&+ subp>agraph 7,a77ii71 ) respect to paym5ts made "u ?is title = specific categories ( s]vices1 ! ,secret>y may ent] into contracts "u p>agraph 7#a7 t provide = a retrospective p]iod dur+ :i* audit & recov]y activities may be conduct$ ( n m ?an #c ye>s4 4 7d7 ,report on ,,rac paym5t /ructure ,n lat] ?an #f mon?s aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices %all submit to ,congress a report on ways to *ange1 9 a budget neutral mann]1 ! paym5t /ructure = recov]y audit contractors "u section #ahic7;h77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h77#a77 f an inc5tive-bas$ model to a non-inc5tive bas$ approa* t does n impose additional f9ancial burd5s on provid]s4 7e7 ,effective date ,! am5dm5ts made by ?is section %all take effect on ,janu>y #a1 #bjag1 & %all apply to contracts betwe5 ! ,secret>y & recov]y audit contractors ent]$ into on or aft] su* date4 #ac4 ,inc5tives & dis9c5tives = ,m$ic>e contractors1 provid]s1 & suppli]s ,section #ahic ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd71 z am5d$ by section #aj1 is fur!r am5d$-- 7#a7 by r$esignat+ subsection 7j7 z subsection 7k72 & 7#b7 by ins]t+ aft] subsection 7i7 ! foll[+ new subsection3 7j7 ,compliance inc5tive program 7#a7 ,9 g5]al ,n lat] ?an ,janu>y #a1 #bjag1 ! ,secret>y %all e/abli% a compliance inc5tive program1 consi/+ ( ! compon5ts describ$ 9 p>agraphs 7#b7 & 7#c71 to enc\rage-- 7,a7 provid]s ( s]vices & suppli]s to submit accurate claims t comply ) ?is title & ! policies1 regulations1 & program in/ructions promulgat$ !reund]1 z well z any applicable national or local cov]age det]m9ations2 & 7,b7 entities t h ent]$ into contracts ) ! ,secret>y "u subsection 7h7 or section #ahgd;,a 7ref]r$ to 9 ?is subsection z review contractors7 to conduct reviews "u ?is section or section #ahgd;,a1 z applicable1 9 a mann] t is consi/5t ) ! provisions ( ?is title & ! claim review guidel9es1 regulations1 & program in/ructions promulgat$ !reund]1 z well z any applicable national or local cov]age det]m9ations4 7#b7 ,compliance ) claim proc$ures by provid]s ( s]vices & suppli]s 7,a7 ,9 g5]al ,n lat] ?an ,janu>y #a1 #bjag1 ! ,secret>y %all e/abli% a sy/em ?r\gh :i* a provid] ( s]vices or suppli] t has a*iev$ a l[ rate ( d5ials ( claims = paym5t subject to additional docum5tation reque/s ov] a #b ye> p]iod1 z det]m9$ by ! ,secret>y1 %all be exempt = a p]iod ( #a ye> f any po/-paym5t review ( claims = paym5t conduct$ by review contractors4 7,b7 ,limitation ,! ,secret>y %all n exempt or %all resc9d an exemption grant$ to a provid] ( s]vices or suppli] "u subp>agraph 7,a7 if ! ,secret>y det]m9es t !re is evid5ce ( sy/ematic gam+1 fraud1 abuse1 or delay 9 ! provision ( s]vices or items by su* provid] or s]vices or suppli]4 7#c7 ,compliance ) review proc$ures by ,m$ic>e contractors 7,a7 ,9 g5]al ,n lat] ?an ,janu>y #a1 #bjag1 ! ,secret>y %all e/abli% a process1 :i* may include ! use ( sampl+1 = det]m9+ ! frequ5cy ) :i* ! decisions made by a review contractor ) respect to reviews conduct$ "u ?is section or section #ahgd;,a are consi/5t ) ! provisions ( ?is title & ! policies1 regulations1 & program in/ructions promulgat$ !reund]1 z well z any applicable national or local cov]age det]m9ations4 ,! results ( ?is process %all be made available to ! public on ! ,int]net website ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices4 7,b7 ,access to m$ical records by review contractors 7i7 ,access to records bas$ on p]=mance review ,n lat] ?an ,janu>y #a1 #bjag1 ! ,secret>y %all e/abli% a sy/em "u :i*1 = any inc5tive p]iod-- 7,i7 ! numb] ( m$ical records t a review contractor t 0 a high-p]=m+ review contractor 9 ! p]=mance review p]iod associat$ ) su* inc5tive p]iod may reque/ f a provid] ( s]vices or suppli] 9 c>ry+ out activities "u ?is section or section #ahgd1 z applicable1 may be increas$ 7on a slid+ scale72 & 7,,ii7 ! numb] ( m$ical records t a review contractor t 0 a l[-p]=m+ review contractor 9 ! p]=mance review p]iod associat$ ) su* inc5tive p]iod may reque/ f a provid] ( s]vices or suppli] 9 c>ry+ out activities "u ?is section or section #ahgd;,a1 z applicable1 may be decreas$ 7on a slid+ scale74 7ii7 ,def9itions ,9 ?is subp>agraph3 7,i7 ,high-p]=m+ review contractor ,! t]m high-p]=m+ review contractor means a review contractor t1 = a giv5 p]=mance review p]iod1 makes decisions ) respect to reviews conduct$ "u ?is section or section #ahgd;,a1 z applicable1 ( ! activities ( provid]s ( s]vices & suppli]s t are consi/5t ) ! provisions ( ?is title & ! policies1 regulations1 & program in/ructions promulgat$ !reund]1 z well z any applicable national or local cov]age det]m9ations1 at a rate t is equal to or great] ?an #ie p]c5t4 7,,ii7 ,inc5tive p]iod ,! t]m inc5tive p]iod means1 ) respect to a p]=mance review p]iod1 a p]iod ( "t 7to be det]m9$ by ! ,secret>y7 foll[+ su* p]=mance review p]iod dur+ :i* ! numb] ( m$ical records t a review contractor may reque/ f a provid] ( s]vices or suppli] may be increas$ or decreas$ bas$ on su* contractor's /atus z a high-p]=m+ review contractor or a l[-p]=m+ review contractor = su* p]=mance review p]iod4 7,,iii7 ,l[-p]=m+ review contractor ,! t]m l[-p]=m+ review contractor means a review contractor t1 = a giv5 p]=mance review p]iod1 is n describ$ 9 subclause 7,i74 7,,iv7 ,p]=mance review p]iod ,! t]m p]=mance review p]iod means a p]iod ( "t 7to be det]m9$ by ! ,secret>y7 dur+ :i* a review contractor's decisions ) respect to reviews conduct$ "u ?is section or section #ahgd;,a1 z applicable1 are evaluat$ to det]m9e if su* review contractor is a high-p]=m+ contractor or a l[-p]=m+ contractor = su* p]iod4 4 ,decemb] #h1 #bjae,read twice & plac$ on ! cal5d>