,,ii  #aaf? ,,congress  #a/ ,session    
,s4 #cjgh  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,decemb] #ag1 #bjai,mr4
 ,grassley 7= himself & ,mr4 ,wyd57     
introduc$ ! foll[+ bill2 :i* 0 read     
twice & ref]r$ to ! ,committee on       
,f9ance  ,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$ic>e ,act ( #bjai or ! ,,afirm    
,act4  7b7 ,table ( cont5ts ,! table (  
cont5ts = ?is ,act is z foll[s3 ,sec4   
#a4 ,%ort title2 table ( cont5ts4,sec4  
#b4 ,au?ority to e/abli% a process to   
review l[ value claims2 revision ( am\nt
 9 controv]sy ?re%olds4,sec4 #c4 ,rem&+ 
appeals to ! r$et]m9ation level ) !     
introduction ( new evid5ce4,sec4 #d4    
,exp$it$ access to appeals4,sec4 #e4    
,au?ority to use sampl+ & extrapolation 
me?odologies & to consolidate appeals = 

adm9i/rative effici5cy4,sec4 #f4        
,id5tification & ref]ral ( fraud4,sec4  
#g4 ,/udy to assess he>+                
p>ticipation4,sec4 #h4 ,improvem5ts to !
 ,(fice ( ,m$ic>e ,he>+s &              
,appeals4,sec4 #i4 ,review program      
improvem5ts4,sec4 #aj4 ,creation (      
,m$ic>e ,provid] & ,suppli] ,ombudsman =
 ,reviews & ,appeals4,sec4 #aa4 ,limit+ 
! audit & recov]y p]iod = pati5t /atus  
reviews4,sec4 #ab4 ,inc5tives &         
dis9c5tives = ,m$ic>e contractors1      
provid]s1 & suppli]s4  #b4 ,au?ority to 
e/abli% a process to review l[ value    
claims2 revision ( am\nt 9 controv]sy   
?re%olds  7a7 ,au?ority ,to e/abli% a   
process ,to review l[ value claims  7#a7
 ,9 g5]al ,section #ahfi7;b7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          
#acie;ff7b77 is am5d$ by add+ at ! end !
 foll[+ new p>agraph3  7#d7 ,conduct (  
reviews by ,m$ic>e magi/rates  7,a7 ,9  
g5]al ,! ,secret>y %all e/abli%1 ?r\gh  
regulations1 a process "u :i* appeal$   
claims may be review$ by (ficials )9 !  

,(fice ( ,m$ic>e ,he>+s & ,appeals to be
 kn[n z ,m$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$iti\sly4  4   
7#b7 ,con=m+ am5dm5t ,section           
#ahfi7;b77#a77;,a7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acie;ff7b77#a77;,a771 z am5d$ by       
section #d7;b77#c71 is am5d$ by ins]t+ &
 p>agraph 7#d7 aft] subject to          
subp>agraphs 7,d71 7,e71 & 7,h74  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$ic>e magi/rate "u 
p>agraph 7#d71 or a he>+ by an          
adm9i/rative law judge "u ?is subsection
 or subsection 7d71 %all n be available 
to an individual if ! am\nt 9 controv]sy
 is less ?an #afj2  7,,ii7 a review by a
 ,m$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 #a1fcj4  2    
7,b7 9 clause 7iii7-- 7i7 by /rik+ ,=   
reque/s = he>+s & ins]t+ ,= reque/s =   
,m$ic>e magi/rate reviews1 he>+s12  7ii7
 by /rik+ #bjjd & ins]t+ #bjba2 &  7iii7
 by /rik+ #bjjc & ins]t+ #bjbj2 &  7,c7 
by add+ at ! end ! foll[+ new clause3   
7iv7 ,judicial review ,judicial review  
%all n be available to an individual "u 
?is section if ! am\nt 9 controv]sy is  
less ?an ! am\nt specifi$ 9 clause      
7i77,,iii7 7z adju/$ "u clause 7iii774  
4  7#b7 ,con=m+ am5dm5ts  7,a7 ,section 
#aaee ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #acbj;c-#d71 z am5d$ by       
section #d7;b77#a71 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 ins]t+ aft] ! f\r? s5t5ce ! 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#e771 z  
am5d$ by section #d7;b77#b71 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;,b771 z am5d$ by section
 #d7;b77#d71 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 ! f\r? 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 #bjba4  
#c4 ,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$ to b5efits "u "p ,a or enroll$  
"u "p ,b1 or bo?1 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 new            
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 a l[]-level      
adjudicator's inadv]t5t omission or     
errone\s decision to omit su* 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 ! basis ( a
 previ\s adjudication2 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 #bjbj1 & %all apply to new  
appeals fil$ on or aft] su* date4  #d4  
,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 = decisions  
on ! record  7i7 ,decision on ! record  
,n lat] ?an #a ye> aft] ! date ( !      
enactm5t ( ?is subp>agraph1 ! ,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 ,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 
4  7b7 ,con=m+ am5dm5ts  7#a7 ,section  
#aaee ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #acbj;c-#d7 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#e77 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;,a77 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;,b77 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 ,unless o!rwise        
specifi$1 ! am5dm5ts made by subsections
 7a7 & 7b7 %all take effect on ! date ( 
! enactm5t ( ?is ,act & %all apply to   
cases t are p5d+ z ( su* date4  #e4     
,au?ority to use sampl+ & extrapolation 
me?odologies & to consolidate appeals = 
adm9i/rative effici5cy  7a7 ,9 g5]al    
,section #ahfi ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #acie;ff7 is am5d$  
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 appellant2  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 may e/abli% by      
regulation4  7,b7 ,deadl9es ,! ,secret>y
 may e/abli% applicable timeframes =    
appellants to reque/ consolidations & = 
adjudicators to issue 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  7#a7 ,9 g5]al ,except 
z provid$ 9 p>agraph 7#b71 ! am5dm5ts   
made by ?is section %all apply to       
reque/s = review t are fil$ aft] ! date 
( ! enactm5t ( ?is ,act4  7#b7          
,exception ,! requirem5ts describ$ 9    
subsection 7j77#b7 ( section #ahfi ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#acie;ff71 z add$ by subsection 7a71    
%all apply to reque/s = review & reque/s
 = he>+ t are p5d+ at any level ( appeal
 z ( ! date ( enactm5t ( ?is ,act & to  
^? fil$ aft] su* date4  #f4             
,id5tification & ref]ral ( fraud ,n lat]
 ?an #a ye> aft] ! date ( enactm5t ( ?is
 ,act1 ! ,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 
#g4 ,/udy to assess he>+ p>ticipation   
7a7 ,/udy ,n lat] ?an #a ye> aft] ! date
 ( enactm5t ( ?is ,act1 ! ,secret>y (   
,heal? & ,human ,s]vices %all conduct a 
/udy to det]m9e :e!r x w\ld be feasible 
to co/-effectively 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$ic>e adm9i/rative     
contractors "u section #ahgd;,a ( su*   
,act 7#db ,u4,s4,c4 #aciekk-#a72  7#d7  
entities s]v+ z recov]y audit           
contractors "u section #ahic7;h7 ( su*  
,act 7#db ,u4,s4,c4 #acie;ddd7h772 &    
7#e7 o!r ,m$ic>e claims review entities 
det]m9$ appropriate by ! ,secret>y4  7b7
 ,report ,n lat] ?an #b ye>s 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  #h4 ,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$ic>e magi/rates2  7#b7 
by /rik+ ,! ,secret>y & ins]t+ ! foll[+3
  7,a7 ,cont9u+ education requirem5t ,! 
,secret>y  2  7#c7 by ins]t+ &1 beg9n+ 9
 #bjbj1 to ,m$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+ ) cal5d>   
ye> #bjbj1 ea* cal5d> 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 ,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 #bjbj1
 & annually !reaft]1 ! ,secret>y (      
,heal? & ,human ,s]vices %all publi% &  
ma9ta9 on ! ,int]net website ( !        
,dep>tm5t ( ,heal? & ,human ,s]vices !  
foll[+ in=mation 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* type ( s]vice1 !
 p]c5tage ( appeals t receiv$ fully     
favorable1 p>tially favorable1 &        
unfavorable decisions4  7,c7 ,! av]age  
l5g? ( "t elaps$ betwe5 ! initial reque/

 = review & a f9al decision4  7,d7 ,su* 
o!r in=mation z ! ,secret>y det]m9es    
necess>y to ensure great] transp>5cy = !
 ,(fice ( ,m$ic>e ,he>+s & ,appeals4  4 
#i4 ,review program improvem5ts  7a7 ,9 
g5]al ,section #ahic ( ! ,social        
,security ,act 7#db ,u4,s4,c4 #acie;ddd7
 is am5d$-- 7#a7 9 subsection 7b71 by   
add+ at ! end ! foll[+ new p>agraph3    
7#g7 ,! review program improvem5ts      
describ$ 9 subsection 7k74  2 &  7#b7 by
 add+ at ! end ! foll[+ new subsection3 
7k7 ,review program improvem5ts  7#a7 ,9
 g5]al  7,a7 ,guidel9es  7i7 ,9 g5]al   
,to promote 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 e/abli%     
claim review guidel9es = review         
contractors = 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 contractors1 ,m$ic>e magi/rates1 
adm9i/rative law judges1 & appropriate  
memb]s ( ! ,dep>tm5tal ,appeals ,bo>d   
are tra9$ 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$]al ,hospital ,insurance ,tru/ ,fund 
"u section #ahag or ! ,f$]al            
,supplem5t>y ,m$ical ,insurance ,tru/   

,fund "u section #ahda1 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$ic>e      
,paym5t ,advisory ,commission4  7,b7    
,develop me?ods design$ to m9imize1 us+ 
available data1 unnecess>y duplicate    
reviews by review contractors4  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$uce !     
burd5 on provid]s ( s]vices & suppli]s1 
includ+ a uni=m approa* = su* entities  
to notify p>ties ( p5d+ reviews & to    
reque/ m$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$4  7,d7 ,to ! ext5t      
practicable1 id5tify local cov]age      
det]m9ations1 national cov]age          
det]m9ations1 regulations1 & program    
in/ructions issu$ 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$ic>e
 adm9i/rative contractors "u section    
#ahgd;,a & recov]y audit contractors "u 
subsection 7h74  7,f7 ,coord9ate ) !    
,(fice ( ,m$ic>e ,he>+s & ,appeals & !  
,dep>tm5tal ,appeals ,bo>d ( ! ,dep>tm5t

 ( ,heal? & ,human ,s]vices 9 !         
implem5tation ( ! improv$ claim review  
guidel9es & evid5ti>y /&>ds e/abli%$ by 
! provisions (1 & ! am5dm5ts made by1 ! 
,audit  ,appeals ,fairness1 ,integrity1 
& ,re=ms 9 ,m$ic>e ,act ( #bjai1 su* z !
 decision to rem& an appeal4  7,g7      
,ensure t provid]s ( s]vices & suppli]s 
subject to po/-paym5t review by a m$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 be ov]se5 by a m$ical director 
( ! review contractor :o has k (        
relevant ,m$ic>e laws1 regulations1 &   
program in/ruction1 z appropriate4  7,i7
 ,und]take v]ification me?ods1 su* z    
sampl+1 to det]m9e :e!r 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 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  4  7b7 ,annual ,,rac report   
,section #ahic7;h77#h7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acie;ddd7h77#h77 is am5d$ by ins]t+ 1  
&1 ) respect to reports submitt$ aft] ! 
date ( ! enactm5t ( ! ,audit  ,appeals  
,fairness1 ,integrity1 & ,re=ms 9       
,m$ic>e ,act ( #bjai1 ! numb] ( claims  
correct$ 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 (
 ,heal? & ,human ,s]vices to limit !    
au?ority or decisional indep5d5ce (     
,m$ic>e magi/rates1 adm9i/rative law    
judges1 or ! ,dep>tm5tal ,appeals ,bo>d 
( ! ,dep>tm5t ( ,heal? & ,human         
,s]vices4  #aj4 ,creation ( ,m$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  7e7 ,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 
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          
#ahic7k77#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  #aa4 ,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#d77 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$
 to 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* section7 "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  #ab4      
,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$ by add+  

at ! end ! foll[+ new subsection3  7l7  
,compliance inc5tive program  7#a7 ,9   
g5]al ,n lat] ?an #a ye> aft] ! date (  
enactm5t ( ?is subsection1 ! ,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 7ref]r$ to 9
 ?is subsection z review contractors7 to
 conduct reviews "u ?is section 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 #f  

mon?s aft] ! date ( enactm5t ( ?is      
subsection1 ! ,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 a reasonable basis to suspect 
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 #f mon?s aft] ! date ( enactm5t
 ( ?is subsection1 ! ,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 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 #f  
mon?s aft] ! date ( enactm5t ( ?is ,act1
 ! ,secret>y %all e/abli% a sy/em "u    
:i*1 9 addition to any o!r adju/m5ts t !
 ,secret>y may make to ! numb] ( m$ical 
records t a review contractor may       
reque/1 = any inc5tive p]iod--  7,i7 !  
numb] ( m$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   
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   
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 ( !  
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 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