,i #aaeth ,,congress #ast ,session ,h4 ,r4 #bdde ,,in ,,the ,,house ,,of ,,representatives ,may #af1 #bjag,mrs4 ,blackburn introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committee on ,ways and ,means1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to provide for a prior authorization process under the ,medicare program for certain high cost durable medical equipment1 prosthetics1 orthotics1 and supplies4 #a4 ,short title ,this ,act may be cited as the ,,dmepos ,access and ,transparency ,act of #bjag or the ,,data ,act of #bjag4 #b4 ,prior authorization process for certain high cost durable medical equipment1 prosthetics1 orthotics1 and supplies under the medicare program ,section #ahcd7;a77#ae7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7a77#ae77 is amended-- 7#a7 in the paragraph heading1 by striking items and inserting items2 prior authorization process for certain high cost durable medical equipment1 prosthetics1 orthotics1 and supplies2 and 7#b7 by adding at the end the following new subparagraphs3 7,d7 ,prior authorization process for certain high cost durable medical equipment1 prosthetics1 orthotics1 and supplies 7i7 ,in general ,not later than #a year after the date of the enactment of this subparagraph1 the ,secretary shall develop and implement a prior authorization process for certain durable medical equipment1 prosthetics1 orthotics1 and supplies4 ,a claim for an item of durable medical equipment1 a prosthetic1 an orthotic1 or a supply that has received prior approval through the prior authorization process shall be exempt from subsequent pre- and post-payment audits and only subject to audits for systematic fraud and abuse4 7ii7 ,consideration of factors ,the ,secretary shall consider the following factors in developing and implementing the prior authorization process under this subparagraph3 7,i7 ,beneficiary access to timely care4 7,,ii7 ,alignment with the best practices of commercial managed care plans and ,medicare ,advantage plans under part ,c that have expertise in prior authorization processes4 7,,iii7 ,implementation of standard medical necessity evaluation prior authorization requests for physician and hospital referral agents and non-physician practitioners4 7,,iv7 ,accounting for same day delivery expectations by providing for expedited emergency review for certain items4 7iii7 ,implementation ,the ,secretary shall promulgate a regulation to carry out the prior authorization process under this subparagraph4 ,the regulation shall-- 7,i7 ensure that stakeholders participate in the development of the process2 and 7,,ii7 place priority on prior authorization of items that are subject to a high number of contractor audits4 7,e7 ,prior authorization process for home respiratory therapy 7i7 ,in general ,in the case of home respiratory therapy 7as defined in clause 7v77 furnished on or after ,january #a1 #bjai1 the ,secretary shall establish and implement a process under which the ,secretary shall determine1 in advance of furnishing such therapy to an individual1 whether payment for such therapy may not be made under this title because such therapy is not covered under this title or because of the application of section #ahfb7;a77#a74 7ii7 ,elements of process ,under the process described in clause 7i71 with respect to home respiratory therapy for an individual1 the following shall apply3 7,i7 ,in order to obtain a prior authorization under such process1 the prescribing practitioner 7as defined by the ,secretary7 prescribing such therapy for such individual shall submit1 for such therapy and individual-- 7aa7 a prescription2 7bb7 in the case of home respiratory therapy that is oxygen or oxygen equipment1 a certificate of medical necessity2 and 7cc7 a prior authorization form that includes the information described in subclause 7,,ii74 ,a prescription described in item 7aa7 with respect to such therapy is not required under this subclause if a certificate of medical necessity described in item 7bb7 with respect to such therapy is provided and if such certificate contains a narrative description that includes the elements for a prescription1 as set forth by the ,secretary4 7,,ii7 ,the ,secretary shall provide a prior authorization form 7initially on paper and1 not later than #c years after the date of the enactment of this subparagraph1 in an electronic format7 for prescribing practitioners 7as so defined by the ,secretary7 to complete when requesting a prior authorization under this subparagraph4 ,the form shall constitute the complete request for information to determine medical necessity and require the prescribing practitioner 7as so defined by the ,secretary7 to provide each of the following3 7aa7 ,the date that the individual was seen by a prescribing practitioner 7as so defined by the ,secretary7 within the appropriate timeframes for certification of the need for the therapy4 7bb7 ,the result of the original blood gas1 saturation test results1 or sleep study results1 as applicable4 7cc7 ,a statement that the individual needs or is using the therapy4 7,,iii7 ,the ,secretary shall respond to the prescribing practitioner 7as so defined by the ,secretary7 making the prior authorization request within #gb hours 7#c calendar days7 of receiving the request4 ,for hospital discharges1 in the case of home respiratory therapy consisting of equipment or supplies1 the ,secretary shall establish an expedited review process to allow for the equipment or supplies to be delivered on the same day it is ordered4 7,,iv7 ,the ,secretary shall communicate the response to the prescribing practitioner 7as so defined by the ,secretary7 making the prior authorization request and to the supplier designated on the certificate of medical necessity4 7,v7 ,a prior authorization approved under the process shall be deemed to constitute medical necessity for coverage and payment under this title but shall not eliminate the proof of delivery documentation requirement under section #dbd4eg7;c77#ab7 of title #db1 ,code of ,federal ,regulations4 7,,vi7 ,a supplier of home respiratory therapy shall not be required to provide such therapy if a prior authorization request under this subparagraph for such therapy has not been approved4 7iii7 ,effect of prior authorization ,the approval of a prior authorization request under this subparagraph shall constitute a finding of medical necessity4 ,the ,secretary may not subject claims with such a prior authorization to pre- or post-payment audit for the purpose of determining medical necessity or improper payment reviews as they relate to documenting medical necessity4 7iv7 ,implementation ,the ,secretary may carry out this subparagraph through notice and comment rulemaking or by interim final rule with comment period4 ,in establishing and implementing the process under this subparagraph1 the ,secretary shall consult with stakeholders through formal and informal mechanisms4 7v7 ,home respiratory therapy defined ,for purposes of this subparagraph1 the term home respiratory therapy means-- 7,i7 equipment1 supplies1 and services for home oxygen1 home sleep1 and mechanical ventilation2 and 7,,ii7 any other equipment1 supply1 or service specified by the ,secretary by regulation4 4