,,ii  #aaf? ,,congress  #b;d ,session   
,s4 #ejdd  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,decemb] #ag1 #bjbj,mr4
 ,br[n 7= himself & ,mr4 ,?une7         
introduc$ ! foll[+ bill2 :i* 0 read     
twice & ref]r$ to ! ,committee on       
,f9ance  ,a ,,bill  ,to am5d title      
,,xviii ( ! ,social ,security ,act to   
e/abli% requirem5ts ) respect to ! use (
 prior au?orization "u ,m$ic>e          
,advantage plans1 & = o!r purposes  #a4 
,%ort title ,?is ,act may be cit$ z !   
,improv+ ,s5iors' ,timely ,access to    
,c>e ,act ( #bjbj4  #b4 ,e/abli%+       
requirem5ts ) respect to ! use ( prior  
au?orization "u ,m$ic>e ,advantage plans
  7a7 ,9 g5]al ,section #aheb ( !       
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#bb7 is am5d$ by add+ at ! end ! 
foll[+ new subsection3  7o7 ,prior      
au?orization requirem5ts  7#a7 ,9 g5]al 
,beg9n+ ) ! second plan ye> beg9n+ aft] 
! date ( ! enactm5t ( ?is subsection1 9 
! case ( a ,m$ic>e ,advantage plan t    
imposes any prior au?orization          

requirem5t ) respect to any applicable  
item or s]vice 7o!r ?an a cov]$ "p ,d   
drug7 dur+ a plan ye>1 su* plan %all--  
7,a7 e/abli% ! electronic prior         
au?orization program describ$ 9 p>agraph
 7#b7 & issue real-"t decisions )       
respect to prior au?orization reque/s = 
items & s]vices id5tifi$ by ! ,secret>y 
"u subp>agraph 7,c77ii7 ( su* p>agraph2 
7,b7 meet ! transp>5cy requirem5ts      
specifi$ 9 p>agraph 7#c72 &  7,c7 meet !
 b5efici>y protection /&>ds specifi$    
pursuant to p>agraph 7#d74  7#b7        
,electronic prior au?orization program  
7,a7 ,9 g5]al ,= purposes ( p>agraph    
7#a77;,a71 ! electronic prior           
au?orization program describ$ 9 ?is     
p>agraph is a program t provides = !    
secure electronic transmission (-- 7i7 a
 prior au?orization reque/ f a heal? c>e
 pr(essional to a ,m$ic>e ,advantage    
plan ) respect to an applicable item or 
s]vice to be furni%$ to an individual1  
includ+ su* cl9ical in=mation necess>y  
to evid5ce m$ical necessity2 &  7ii7 a  

response1 9 accordance ) ?is p>agraph1 f
 su* plan to su* pr(essional4  7,b7     
,electronic transmission  7i7           
,exclusions ,= purposes ( ?is p>agraph1 
a facsimile1 a propriet>y pay] portal t 
does n meet /&>ds specifi$ by !         
,secret>y1 or an electronic =m %all n be
 treat$ z an electronic transmission    
describ$ 9 subp>agraph 7,a74  7ii7      
,/&>ds  7,i7 ,9 g5]al ,9 ord] to ensure 
appropriate cl9ical outcome =           
individuals1 = purposes ( ?is p>agraph1 
an electronic transmission describ$ 9   
subp>agraph 7,a7 %all comply ) te*nical 
/&>ds adopt$ by ! ,secret>y 9           
consultation ) /&>d-sett+ organizations 
det]m9$ appropriate by ! ,secret>y1     
heal? c>e pr(essionals1 ,m$ic>e         
,advantage organizations1 & heal?       
in=mation te*nology s(tw>e v5dors4 ,9   
adopt+ su* /&>ds ) respect to :i* an    
electronic transmission describ$ 9      
subp>agraph 7,a7 %all comply1 !         
,secret>y %all ensure t su*             
transmissions support atta*m5ts conta9+ 

applicable cl9ical in=mation & %all     
prioritize ! adoption ( /&>ds t support 
integration ) int]op]able heal?         
in=mation te*nology c]tifi$ "u a program
 ( volunt>y c]tification kept or        
recogniz$ by ! ,national ,coord9ator =  
,heal? ,in=mation ,te*nology consi/5t ) 
section #cjja7;c77#e7 ( ! ,public ,heal?
 ,s]vice ,act4  7,,ii7 ,transaction /&>d
 ,! ,secret>y %all include 9 ! /&>ds    
adopt$ "u subclause 7,i7 a /&>d )       
respect to ! transmission ( atta*m5ts   
describ$ 9 su* subclause1 & data elem5ts
 & op]at+ rules = su* transmission1     
consi/5t ) heal? c>e indu/ry /&>ds4     
7,c7 ,real-"t decisions  7i7 ,9 g5]al ,!
 program describ$ 9 subp>agraph 7,a7    
%all provide = real-"t decisions 7z     
def9$ by ! ,secret>y 9 accordance )     
clause 7iv77 by a ,m$ic>e ,advantage    
plan ) respect to prior au?orization    
reque/s = applicable items & s]vices    
id5tifi$ by ! ,secret>y pursuant to     
clause 7ii7 = a plan ye> if su* reque/s 
conta9 all docum5tation describ$ 9      

p>agraph 7#c77;,a77ii77,,ii7 requir$ by 
su* plan4  7ii7 ,id5tification ( reque/s
 ,= purposes ( clause 7i7 & ) respect to
 a p]iod ( #b plan ye>s1 ! ,secret>y    
%all id5tify1 n lat] ?an ! date on :i* !
 initial ann\ncem5t describ$ 9 section  
#ahec7;b77#a77;,b77i7 = ! fir/ plan ye> 
( su* p]iod is requir$ to be ann\nc$1   
applicable items & s]vices = :i* prior  
au?orization reque/s are r\t9ely        
approv$1 & %all update ! id5tification (
 su* items & s]vices = ea* subsequ5t    
p]iod ( #b plan ye>s4  7iii7 ,data      
collection & consultation ) relevant    
eligible pr(essional organizations &    
relevant /akehold]s ,! ,secret>y %all   
use ! in=mation describ$ 9 p>agraph     
7#c77;,a7 7if available7 & %all issue a 
reque/ = in=mation f ,m$ic>e ,advantage 
plans1 provid]s1 suppli]s1 b5efici>y    
advocacy organizations1 consum]         
organizations1 & o!r /akehold]s =       
purposes ( id5tify+ reque/s = a p]iod "u
 clause 7ii74  7iv7 ,def9ition ( real-"t
 decision  7,i7 ,9 g5]al ,9 e/abli%+ !  

def9ition ( a real-"t decision =        
purposes ( clause 7i71 ! ,secret>y %all 
take into acc\nt curr5t m$ical practice1
 te*nology1 heal? c>e indu/ry /&>ds1 &  
o!r relevant in=mation & factors to     
ensure ! accurate & timely furni%+ (    
items & s]vices to individuals4  7,,ii7 
,update ,! ,secret>y %all update1 n less
 (t5 ?an once e #b ye>s1 ! def9ition ( a
 real-"t decision = purposes ( clause   
7i71 tak+ into acc\nt *anges 9 m$ical   
practice1 *anges 9 te*nology1 *anges 9  
heal? c>e indu/ry /&>ds1 & o!r relevant 
in=mation1 su* z ! in=mation submitt$ by
 ,m$ic>e ,advantage plans "u p>agraph   
7#c77;,a77i71 & factors to ensure !     
accurate & timely furni%+ ( items &     
s]vices to individuals4  7v7            
,implem5tation ,! ,secret>y %all use    
notice & comm5t rulemak+1 :i* may       
include use ( ! annual call lett]       
process "u ?is "p1 = ea* ( ! foll[+3    
7,i7 ,e/abli%+ ! def9ition ( a real-"t  
decision = purposes ( clause 7i74       
7,,ii7 ,updat+ su* def9ition pursuant to

 clause 7iv77,,ii74  7,,iii7 ,id5tify+  
applicable items or s]vices pursuant to 
clause 7ii7 = ! initial p]iod ( #b plan 
ye>s z describ$ 9 su* clause4  7,,iv7   
,updat+ ! id5tification ( su* items &   
s]vices = ea* subsequ5t p]iod ( #b plan 
ye>s z describ$ 9 su* clause4  7#c7     
,transp>5cy requirem5ts  7,a7 ,9 g5]al  
,= purposes ( p>agraph 7#a77;,b71 !     
transp>5cy requirem5ts specifi$ 9 ?is   
p>agraph are1 ) respect to a ,m$ic>e    
,advantage plan1 ! foll[+3 7i7 ,! plan1 
annually & 9 a mann] specifi$ by !      
,secret>y1 %all submit to ! ,secret>y ! 
foll[+ in=mation3 7,i7 ,a li/ ( all     
applicable items & s]vices t are        
describ$ 9 subsection 7a77#a77;,b7 t are
 subject to a prior au?orization        
requirem5t "u ! plan4  7,,ii7 ,!        
p]c5tage ( prior au?orization reque/s   
approv$ dur+ ! previ\s plan ye> by !    
plan 9 an initial det]m9ation ) respect 
to ea* su* item & s]vice4  7,,iii7 ,!   
p]c5tage ( su* reque/s t 7 initially    
d5i$ & t 7 subsequ5tly appeal$ 9 any    

mann]1 & ! p]c5tage ( su* appeal$       
reque/s t 7 ov]turn$1 ) respect to ea*  
su* item & s]vice1 brok5 d[n by ea* /age
 ( appeal 7includ+ judicial review74 ,! 
plan may include in=mation reg>d+ !     
numb] ( initial d5ials due to reque/    
submissions t did n meet cl9ical evid5ce
 /&>ds4  7,,iv7 ,! p]c5tage ( su*       
reque/s t 7 d5i$ & ! p]c5tage ( ! total 
numb] ( d5i$ reque/s t 7 d5i$ z a result
 ( decision support te*nology or o!r    
cl9ical decision-mak+ tools4  7,v7 ,!   
av]age & ! m$ian am\nt ( "t 79 h\rs7 t  
elaps$ dur+ ! previ\s plan ye> betwe5 ! 
submission ( su* a reque/ to ! plan & a 
det]m9ation by ! plan ) respect to su*  
reque/ = ea* su* item & s]vice1 exclud+ 
any su* reque/s t did n conta9 all      
in=mation requir$ to be submitt$ by !   
plan4  7,,vi7 ,a li/ t includes a       
description ( ea* occurr5ce dur+ !      
previ\s plan ye> 9 :i* ! plan made a    
det]m9ation to approve or d5y an item or
 s]vice 9 ! case :]e a provid] furni%$  
an additional or diff]+ item or s]vice  

dur+ ! p]op]ative p]iod ( a surgical or 
o!rwise invasive proc$ure t su* provid] 
det]m9$ 0 m$ically necess>y4  7,,vii7 ,a
 disclosure & description ( any s(tw>e  
decision-mak+ tools ! plan utilizes 9   
mak+ det]m9ations ) respect to su*      
reque/s4  7,,viii7 ,su* o!r in=mation z 
! ,secret>y det]m9es appropriate4  7ii7 
,! plan %all provide-- 7,i7 to ea*      
provid] or suppli] :o seeks to ent] into
 a contract ) su* plan to furni%        
applicable items & s]vices "u su* plan1 
! li/ describ$ 9 clause 7i77,i7 & any   
policies or proc$ures us$ by ! plan =   
mak+ det]m9ations ) respect to prior    
au?orization reque/s2  7,,ii7 to ea* su*
 provid] & suppli] :o does ent] into su*
 a contract1 access to ! crit]ia us$ by 
! plan = mak+ su* det]m9ations1 includ+ 
an itemization ( ! m$ical or o!r        
docum5tation requir$ to be submitt$ by a
 provid] or suppli] ) respect to su* a  
reque/1 except to ! ext5t t provision ( 
access to su* crit]ia w\ld disclose     
propriet>y in=mation ( su* plan2 &      

7,,iii7 to ea* b5efici>y subject to     
prior au?orization "u ! plan1 access to 
! crit]ia us$ by ! plan = mak+ su*      
det]m9ations1 except to ! ext5t t       
provision ( access to su* crit]ia w\ld  
disclose propriet>y in=mation ( su*     
plan4  7,b7 ,regulations ,! ,secret>y   
%all1 ?r\gh notice & comm5t rulemak+1   
provide guidance to ,m$ic>e ,advantage  
plans reg>d+-- 7i7 ! e/abli%m5t (       
crit]ia describ$ 9 subp>agraph          
7,a77ii77,,ii7 & access to su* crit]ia  
by provid]s & suppli]s 9 accordance )   
su* subp>agraph2 &  7ii7 access to su*  
crit]ia by b5efici>ies 9 accordance )   
subp>agraph 7,a77ii77,,iii74  7,c7      
,med,pac report ,n lat] ?an #c ye>s aft]
 ! date in=mation is fir/ submitt$ "u   
subp>agraph 7,a77i71 ! ,m$ic>e ,paym5t  
,advisory ,commission %all submit to    
,congress a report on su* in=mation t   
includes a descriptive analysis ( ! use 
( prior au?orization4 ,z appropriate1 ! 
,commission %\ld report on /ati/ics     
includ+ ! frequ5cy ( appeals & ov]turn$ 

decisions4 ,! ,commission %all provide  
recomm5dations1 z appropriate1 on any   
improvem5t t %\ld be made to !          
electronic prior au?orization programs (
 ,m$ic>e ,advantage plans4  7#d7        
,b5efici>y protection /&>ds ,! ,secret>y
 ( ,heal? & ,human ,s]vices %all1 ?r\gh 
notice & comm5t rulemak+1 specify       
requirem5ts ) respect to ! use ( prior  
au?orization by ,m$ic>e ,advantage plans
 = applicable items & s]vices to        
ensure-- 7,a7 t su* plans adopt         
transp>5t prior au?orization programs   
develop$ 9 consultation ) provid]s &    
suppli]s ) contracts 9 effect ) su*     
plans = furni%+ su* items & s]vices "u  
su* plans t all[ = ! modification (     
prior au?orization requirem5ts bas$ on !
 p]=mance ( su* provid]s & suppli]s )   
respect to adh]5ce to evid5ce-bas$      
m$ical guidel9es & o!r quality crit]ia2 
7,b7 t su* plans conduct annual reviews 
( su* items & s]vices = :i* prior       
au?orization requirem5ts are impos$ "u  
su* plans ?r\gh a process t takes into  

acc\nt input f provid]s & suppli]s ) su*
 contracts 9 effect & is bas$ on        
analysis ( pa/ prior au?orization       
reque/s & curr5t cov]age & cl9ical      
crit]ia2  7,c7 cont9uity ( c>e =        
individuals transition+ to1 or betwe51  
cov]age "u su* plans 9 ord] to m9imize  
any disruption to ongo+ treatm5t        
attributable to prior au?orization      
requirem5ts "u su* plans2  7,d7 t su*   
plans make timely prior au?orization    
det]m9ations1 provide rationales =      
d5ials1 & ensure reque/s are review$ by 
qualifi$ m$ical p]sonnel2 &  7,e7 t su* 
plans provide in=mation on ! appeals    
process to ! b5efici>y :5 d5y+ any      
reque/ = prior au?orization ) respect to
 an item or s]vice4  7#e7 ,applicable   
item or s]vice ,= purposes ( ?is        
subsection1 ! t]m applicable item or    
s]vice means1 ) respect to a ,m$ic>e    
,advantage plan1 any item or s]vice =   
:i* b5efits are available "u su* plan1  
o!r ?an a cov]$ "p ,d drug4  7#f7       
,report to ,congress ,n lat] ?an ! end (

 ! second plan ye> beg9n+ on or aft] !  
date ( ! enactm5t ( ?is subsection1 &   
bi5nially !reaft] ?r\gh ! date t is #aj 
ye>s aft] su* date ( enactm5t1 !        
,secret>y %all submit to ,congress a    
report conta9+ an evaluation ( !        
implem5tation ( ! requirem5ts ( ?is     
subsection1 an analysis ( an issues 9   
implem5t+ su* requirem5ts fac$ by       
,m$ic>e ,advantage plans1 & a           
description ( ! in=mation submitt$ "u   
p>agraph 7#c77;,a77i7 ) respect to--    
7,a7 9 ! case ( ! fir/ su* report1 su*  
second plan ye>2 &  7,b7 9 ! case ( a   
subsequ5t report1 ! #b full plan ye>s   
prec$+ ! date ( ! submission ( su*      
report4  4  7b7 ,det]m9ation            
cl>ification ,section #aheb7;g77#a77;,a7
 ( ! ,social ,security ,act 7#db        
,u4,s4,c4 #aciew-#bb7;g77#a77;,a77 is   
am5d$ by ins]t+ 7includ+ any decision   
made ) respect to a prior au?orization  
reque/ = su* s]vice7 aft] section4