,i  #aahth ,,congress  #ast ,session    
,h4 ,r4 #ebac  ,,in ,,the ,,house ,,of  
,,representatives  ,august #ae1 #bjbc   
,mr4 ,green of ,tennessee introduced the
 following bill2 which was referred to  
the ,committee on ,ways and ,means1 and 
in addition to the ,committee on ,energy
 and ,commerce1 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 ensure that prior        
authorization medical decisions under   
,medicare are determined by physicians4 
#a4 ,short title ,this ,act may be cited
 as the ,reducing ,medically            
,unnecessary ,delays in ,care ,act of   
#bjbc4  #b4 ,definitions ,in this ,act3 
7#a7 ,adverse determination ,the term   
adverse determination means a decision  
by a medicare administrative contractor1
 ,medicare ,advantage plan1 or          
prescription drug plan that administers 
prior authorization programs under the  

,medicare program under title ,,xviii of
 the ,social ,security ,act or such plan
 that the health care services furnished
 or proposed to be furnished to an      
individual entitled to benefits or      
enrolled under the ,medicare program are
 not medically necessary1 or are        
experimental or investigational2 and    
benefit coverage under such program or  
plan for such services is therefore     
denied1 reduced1 or terminated4  7#b7   
,authorization ,the term authorization  
means a determination by a medicare     
administrative contractor1 ,medicare    
,advantage plan1 or prescription drug   
plan that administers prior             
authorization programs under the        
,medicare program under title ,,xviii of
 the ,social ,security ,act or such plan
 that a health care service has been    
reviewed and1 based on the information  
provided1 satisfies the utilization     
review entity's requirements for medical
 necessity and appropriateness and that 
payment will be made under the ,medicare

 program under title ,,xviii of the     
,social ,security ,act or such plan for 
that health care service4  7#c7         
,clinical criteria ,the term clinical   
criteria means the written policies1    
written screening procedures1 drug      
formularies1 or lists of covered drugs1 
decision rules1 decision abstracts1     
clinical protocols1 practice guidelines1
 and medical protocols used by a        
medicare administrative contractor1     
,medicare ,advantage plan1 or           
prescription drug plan to determine the 
necessity and appropriateness of health 
care services4  7#d7 ,final adverse     
determination ,the term final adverse   
determination means an adverse          
determination that has been upheld by a 
medicare administrative contractor1     
,medicare ,advantage plan1 or           
prescription drug plan at the completion
 of the contractor's appeals process4   
7#e7 ,health care service ,the term     
health care service means a health care 
item1 service1 procedure1 treatment1 or 

prescription drug provided by a facility
 licensed in the ,state involved or     
provided by a doctor of medicine1 a     
doctor of osteopathy1 or a health care  
professional licensed in such ,state4   
7#f7 ,medically necessary health care   
service ,the term medically necessary   
health care services means health care  
services that a prudent physician would 
provide to a patient for the purpose of 
preventing1 diagnosing1 or treating an  
illness1 injury1 disease1 or its        
symptoms in a manner that is--  7,a7 in 
accordance with generally accepted      
standards of medical practice2  7,b7    
clinically appropriate in terms of type1
 frequency1 extent1 site1 and duration2 
and  7,c7 not primarily for the economic
 benefit of the health plans and        
purchasers or for the convenience of the
 patient1 treating physician1 or other  
health care provider4  7#g7 ,medicare   
,administrative ,contractor ,the term   
medicare administrative contractor means
 a medicare administrative contractor   

with a contract under section #ahgd;,a  
of the ,social ,security ,act 7#db      
,u4,s4,c4 #aciekk-#a74  7#h7 ,medicare  
,advantage plan ,the term ,medicare     
,advantage plan means a ,medicare       
,advantage plan under part ,c of title  
,,xviii of the ,social ,security ,act4  
7#i7 ,preauthorization ,the term        
preauthorization--  7,a7 means the      
process by which a medicare             
administrative contractor1 ,medicare    
,advantage plan1 or prescription drug   
plan determines the medical necessity or
 medical appropriateness of health care 
services for which benefits are         
otherwise provided under the ,medicare  
program under title ,,xviii of the      
,social ,security ,act or such plan     
prior to the rendering of such health   
care services1 including preadmission   
review1 pretreatment review1            
utilization1 and case management2 and   
7,b7 includes any requirement that a    
patient or health care provider notify  
the ,centers for ,medicare  ,medicaid   

,services prior to providing a health   
care service4  7#aj7 ,prescription drug 
plan ,the term prescription drug plan   
means a prescription drug plan under    
part ,d of title ,,xviii of the ,social 
,security ,act4  #c4 ,contract          
requirements for prior authorization    
medical decisions for ,medicare         
,administrative ,contractors1 ,medicare 
,advantage plans1 and prescription drug 
plans ,any contract that applies on or  
after the date that is #ij days after   
the date of the enactment of this ,act1 
between the ,secretary of ,health and   
,human ,services and a medicare         
administrative contractor under section 
#ahgd;,a of the ,social ,security ,act1 
a ,medicare ,advantage organization     
under section #aheg of such ,act with   
respect to the offering of a ,medicare  
,advantage plan1 or a ,,pdp sponsor     
under section #ahfj;,d-#ab of such ,act 
with respect to the offering of a       
prescription drug plan shall require    
such medicare administrative contractor1

 ,medicare ,advantage plan1 or          
prescription drug plan1 respectively1 to
 comply with each of the following      
requirements3  7#a7 ,medical necessity  
,any restriction1 preauthorization1     
adverse determination1 or final adverse 
determination that the medicare         
administrative contractor1 ,medicare    
,advantage plan1 or prescription drug   
plan1 respectively1 places on the       
provision of a health care service for  
the purposes of coverage or payment of  
such service under the ,medicare program
 under title ,,xviii of such ,act1 or   
under such plan1 shall be based on the  
medical necessity or appropriateness of 
such service and on written clinical    
criteria4  7#b7 ,evidence-based         
standards ,if no independently developed
 evidence-based standards exist for a   
particular health care service1 the     
medicare administrative contractor1     
,medicare ,advantage plan1 or           
prescription drug plan1 respectively1   
may not deny coverage of the health care

 service based solely on the grounds    
that the health care service does not   
meet an evidence-based standard4  7#c7  
,input from physicians ,prior to        
establishing1 or substantially or       
materially altering1 written clinical   
criteria for purpose of preauthorization
 review1 the medicare administrative    
contractor1 ,medicare ,advantage plan1  
or prescription drug plan1 respectively1
 shall obtain input from actively       
practicing physicians within the service
 area where the written clinical        
criteria are to be employed4 ,such      
physicians must represent major areas of
 specialty and be certified by the      
boards of the ,american ,board of       
,medical ,specialties4 ,the medicare    
administrative contractor1 ,medicare    
,advantage plan1 or prescription drug   
plan shall seek input from physicians   
who are not employees of the medicare   
administrative contractor1 ,medicare    
,advantage plan1 or prescription drug   
plan4  7#d7 ,written clinical criteria  

,the medicare administrative contractor1
 ,medicare ,advantage plan1 or          
prescription drug plan1 respectively1   
shall apply written clinical criteria   
for the purpose of preauthorization     
review consistently4 ,such written      
clinical criteria must--  7,a7 be based 
on nationally recognized standards2     
7,b7 be developed in accordance with the
 current standards of national          
accreditation entities2  7,c7 reflect   
community standards of care2  7,d7      
ensure quality of care and access to    
needed health care services2  7,e7 be   
evidence based2  7,f7 be sufficiently   
flexible to allow deviations from norms 
when justified on case-by-case bases2   
and  7,g7 be evaluated and updated if   
necessary at least annually4  7#e7      
,website posting ,the medicare          
administrative contractor1 ,medicare    
,advantage plan1 or prescription drug   
plan1 respectively1 shall make any      
current preauthorization requirements   
and restrictions readily accessible on  

its website to subscribers1 health care 
providers1 and the general public4 ,this
 includes the written clinical criteria4
 ,such requirements must be described in
 detail but also in easily              
understandable language4  7#f7 ,notice  
required for new requirements or        
restrictions ,if the medicare           
administrative contractor1 ,medicare    
,advantage plan1 or prescription drug   
plan1 respectively1 decides to implement
 a new preauthorization requirement or  
restriction1 or amend an existing       
requirement or restriction1 the medicare
 administrative contractor1 ,medicare   
,advantage plan1 or prescription drug   
plan shall provide contracted health    
care providers written notice of the new
 or amended requirement or amendment no 
less than #fj days before the           
requirement or restriction is           
implemented and shall ensure that the   
new or amended requirement has been     
updated on the medicare administrative  
contractor1 ,medicare ,advantage plan1  

or prescription drug plan's website4    
7#g7 ,availability of determinations    
,the medicare administrative contractor1
 ,medicare ,advantage plan1 or          
prescription drug plan1 respectively1   
utilizing preauthorization shall make   
statistics available regarding          
preauthorization approvals and denials  
for coverage or payment of health care  
services under the ,medicare program    
under title ,,xviii of the ,social      
,security ,act or such plan on their    
website in a readily accessible format4 
,the medicare administrative contractor1
 ,medicare ,advantage plan1 or          
prescription drug plan shall include    
categories for--  7,a7 physician        
specialty2  7,b7 medication or          
diagnostic test_/procedure2  7,c7       
indication offered2 and  7,d7 reason for
 denial4  7#h7 ,determinations made by  
physicians ,the medicare administrative 
contractor1 ,medicare ,advantage plan1  
or prescription drug plan1 respectively1
 shall ensure that all preauthorizations

 and adverse determinations are made by 
a physician who possesses a current and 
valid non-restricted license to practice
 medicine in a ,state1 and must be board
 certified or eligible in the same      
specialty as the health care provider   
who typically manages the medical       
condition or disease or provides the    
health care service4 ,the physician must
 make the adverse determination under   
the clinical direction of one of the    
medicare administrative contractor's1   
,medicare ,advantage plan's1 or         
prescription drug plan's medical        
directors who is responsible for the    
provision of health care services and   
who is licensed in such ,state4