,i  #aah? ,,congress  #a/ ,session  ,h4 
,r4 #ebac  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,augu/ #ae1 #bjbc ,mr4
 ,gre5 ( ,t5nessee introduc$ ! foll[+   
bill2 :i* 0 ref]r$ to ! ,committee on   
,ways & ,means1 & 9 addition to !       
,committee on ,en]gy & ,comm]ce1 = a    
p]iod to be subsequ5tly det]m9$ by !    
,speak]1 9 ea* case = consid]ation ( su*
 provisions z fall )9 ! jurisdiction ( !
 committee conc]n$  ,a ,,bill  ,to      
ensure t prior au?orization m$ical      
decisions "u ,m$ic>e are det]m9$ by     
physicians4  #a4 ,%ort title ,?is ,act  
may be cit$ z ! ,r$uc+ ,m$ically        
,unnecess>y ,delays 9 ,c>e ,act ( #bjbc4
  #b4 ,def9itions ,9 ?is ,act3  7#a7    
,adv]se det]m9ation ,! t]m adv]se       
det]m9ation means a decision by a m$ic>e
 adm9i/rative contractor1 ,m$ic>e       
,advantage plan1 or prescription drug   
plan t adm9i/]s prior au?orization      
programs "u ! ,m$ic>e program "u title  
,,xviii ( ! ,social ,security ,act or   
su* plan t ! heal? c>e s]vices furni%$  

or propos$ to be furni%$ to an          
individual entitl$ to b5efits or enroll$
 "u ! ,m$ic>e program are n m$ically    
necess>y1 or are exp]im5tal or          
inve/igational2 & b5efit cov]age "u su* 
program or plan = su* s]vices is !re=e  
d5i$1 r$uc$1 or t]m9at$4  7#b7          
,au?orization ,! t]m au?orization means 
a det]m9ation by a m$ic>e adm9i/rative  
contractor1 ,m$ic>e ,advantage plan1 or 
prescription drug plan t adm9i/]s prior 
au?orization programs "u ! ,m$ic>e      
program "u title ,,xviii ( ! ,social    
,security ,act or su* plan t a heal? c>e
 s]vice has be5 review$ &1 bas$ on !    
in=mation provid$1 satisfies !          
utilization review entity's requirem5ts 
= m$ical necessity & appropriat5ess & t 
paym5t w be made "u ! ,m$ic>e program "u
 title ,,xviii ( ! ,social ,security    
,act or su* plan = t heal? c>e s]vice4  
7#c7 ,cl9ical crit]ia ,! t]m cl9ical    
crit]ia means ! writt5 policies1 writt5 
scre5+ proc$ures1 drug =mul>ies1 or li/s
 ( cov]$ drugs1 decision rules1 decision

 ab/racts1 cl9ical protocols1 practice  
guidel9es1 & m$ical protocols us$ by a  
m$ic>e adm9i/rative contractor1 ,m$ic>e 
,advantage plan1 or prescription drug   
plan to det]m9e ! necessity &           
appropriat5ess ( heal? c>e s]vices4     
7#d7 ,f9al adv]se det]m9ation ,! t]m    
f9al adv]se det]m9ation means an adv]se 
det]m9ation t has be5 upheld by a m$ic>e
 adm9i/rative contractor1 ,m$ic>e       
,advantage plan1 or prescription drug   
plan at ! completion ( ! contractor's   
appeals process4  7#e7 ,heal? c>e s]vice
 ,! t]m heal? c>e s]vice means a heal?  
c>e item1 s]vice1 proc$ure1 treatm5t1 or
 prescription drug provid$ by a facility
 lic5s$ 9 ! ,/ate involv$ or provid$ by 
a doctor ( m$ic9e1 a doctor ( o/eopa?y1 
or a heal? c>e pr(essional lic5s$ 9 su* 
,/ate4  7#f7 ,m$ically necess>y heal?   
c>e s]vice ,! t]m m$ically necess>y     
heal? c>e s]vices means heal? c>e       
s]vices t a prud5t physician w\ld       
provide to a pati5t = ! purpose (       
prev5t+1 diagnos+1 or treat+ an illness1

 injury1 disease1 or its symptoms 9 a   
mann] t is--  7,a7 9 accordance )       
g5]ally accept$ /&>ds ( m$ical practice2
  7,b7 cl9ically appropriate 9 t]ms (   
type1 frequ5cy1 ext5t1 site1 & duration2
 &  7,c7 n prim>ily = ! economic b5efit 
( ! heal? plans & pur*as]s or = !       
conv5i5ce ( ! pati5t1 treat+ physician1 
or o!r heal? c>e provid]4  7#g7 ,m$ic>e 
,adm9i/rative ,contractor ,! t]m m$ic>e 
adm9i/rative contractor means a m$ic>e  
adm9i/rative contractor ) a contract "u 
section #ahgd;,a ( ! ,social ,security  
,act 7#db ,u4,s4,c4 #aciekk-#a74  7#h7  
,m$ic>e ,advantage plan ,! t]m ,m$ic>e  
,advantage plan means a ,m$ic>e         
,advantage plan "u "p ,c ( title ,,xviii
 ( ! ,social ,security ,act4  7#i7      
,preau?orization ,! t]m                 
preau?orization--  7,a7 means ! process 
by :i* a m$ic>e adm9i/rative contractor1
 ,m$ic>e ,advantage plan1 or            
prescription drug plan det]m9es ! m$ical
 necessity or m$ical appropriat5ess (   
heal? c>e s]vices = :i* b5efits are     

o!rwise provid$ "u ! ,m$ic>e program "u 
title ,,xviii ( ! ,social ,security ,act
 or su* plan prior to ! r5d]+ ( su*     
heal? c>e s]vices1 includ+ preadmission 
review1 pretreatm5t review1 utilization1
 & case managem5t2 &  7,b7 includes any 
requirem5t t a pati5t or heal? c>e      
provid] notify ! ,c5t]s = ,m$ic>e       
,m$icaid ,s]vices prior to provid+ a    
heal? c>e s]vice4  7#aj7 ,prescription  
drug plan ,! t]m prescription drug plan 
means a prescription drug plan "u "p ,d 
( title ,,xviii ( ! ,social ,security   
,act4  #c4 ,contract requirem5ts = prior
 au?orization m$ical decisions = ,m$ic>e
 ,adm9i/rative ,contractors1 ,m$ic>e    
,advantage plans1 & prescription drug   
plans ,any contract t applies on or aft]
 ! date t is #ij days aft] ! date ( !   
enactm5t ( ?is ,act1 betwe5 ! ,secret>y 
( ,heal? & ,human ,s]vices & a m$ic>e   
adm9i/rative contractor "u section      
#ahgd;,a ( ! ,social ,security ,act1 a  
,m$ic>e ,advantage organization "u      
section #aheg ( su* ,act ) respect to ! 

(f]+ ( a ,m$ic>e ,advantage plan1 or a  
,,pdp sponsor "u section #ahfj;,d-#ab ( 
su* ,act ) respect to ! (f]+ ( a        
prescription drug plan %all require su* 
m$ic>e adm9i/rative contractor1 ,m$ic>e 
,advantage plan1 or prescription drug   
plan1 respectively1 to comply ) ea* ( ! 
foll[+ requirem5ts3  7#a7 ,m$ical       
necessity ,any re/riction1              
preau?orization1 adv]se det]m9ation1 or 
f9al adv]se det]m9ation t ! m$ic>e      
adm9i/rative contractor1 ,m$ic>e        
,advantage plan1 or prescription drug   
plan1 respectively1 places on !         
provision ( a heal? c>e s]vice = !      
purposes ( cov]age or paym5t ( su*      
s]vice "u ! ,m$ic>e program "u title    
,,xviii ( su* ,act1 or "u su* plan1 %all
 be bas$ on ! m$ical necessity or       
appropriat5ess ( su* s]vice & on writt5 
cl9ical crit]ia4  7#b7 ,evid5ce-bas$    
/&>ds ,if no indep5d5tly develop$       
evid5ce-bas$ /&>ds exi/ = a p>ticul>    
heal? c>e s]vice1 ! m$ic>e adm9i/rative 
contractor1 ,m$ic>e ,advantage plan1 or 

prescription drug plan1 respectively1   
may n d5y cov]age ( ! heal? c>e s]vice  
bas$ solely on ! gr\nds t ! heal? c>e   
s]vice does n meet an evid5ce-bas$ /&>d4
  7#c7 ,input f physicians ,prior to    
e/abli%+1 or sub/antially or mat]ially  
alt]+1 writt5 cl9ical crit]ia = purpose 
( preau?orization review1 ! m$ic>e      
adm9i/rative contractor1 ,m$ic>e        
,advantage plan1 or prescription drug   
plan1 respectively1 %all obta9 input f  
actively practic+ physicians )9 ! s]vice
 area :]e ! writt5 cl9ical crit]ia are  
to be employ$4 ,su* physicians mu/      
repres5t major areas ( specialty & be   
c]tifi$ by ! bo>ds ( ! ,am]ican ,bo>d ( 
,m$ical ,specialties4 ,! m$ic>e         
adm9i/rative contractor1 ,m$ic>e        
,advantage plan1 or prescription drug   
plan %all seek input f physicians :o are
 n employees ( ! m$ic>e adm9i/rative    
contractor1 ,m$ic>e ,advantage plan1 or 
prescription drug plan4  7#d7 ,writt5   
cl9ical crit]ia ,! m$ic>e adm9i/rative  
contractor1 ,m$ic>e ,advantage plan1 or 

prescription drug plan1 respectively1   
%all apply writt5 cl9ical crit]ia = !   
purpose ( preau?orization review        
consi/5tly4 ,su* writt5 cl9ical crit]ia 
mu/--  7,a7 be bas$ on nationally       
recogniz$ /&>ds2  7,b7 be develop$ 9    
accordance ) ! curr5t /&>ds ( national  
accr$itation entities2  7,c7 reflect    
community /&>ds ( c>e2  7,d7 ensure     
quality ( c>e & access to ne$$ heal? c>e
 s]vices2  7,e7 be evid5ce bas$2  7,f7  
be suffici5tly flexible to all[         
deviations f norms :5 ju/ifi$ on        
case-by-case bases2 &  7,g7 be evaluat$ 
& updat$ if necess>y at lea/ annually4  
7#e7 ,website po/+ ,! m$ic>e            
adm9i/rative contractor1 ,m$ic>e        
,advantage plan1 or prescription drug   
plan1 respectively1 %all make any curr5t
 preau?orization requirem5ts &          
re/rictions readily accessible on its   
website to subscrib]s1 heal? c>e        
provid]s1 & ! g5]al public4 ,?is        
includes ! writt5 cl9ical crit]ia4 ,su* 
requirem5ts mu/ be describ$ 9 detail b  

also 9 easily und]/&able language4  7#f7
 ,notice requir$ = new requirem5ts or   
re/rictions ,if ! m$ic>e adm9i/rative   
contractor1 ,m$ic>e ,advantage plan1 or 
prescription drug plan1 respectively1   
decides to implem5t a new               
preau?orization requirem5t or           
re/riction1 or am5d an exi/+ requirem5t 
or re/riction1 ! m$ic>e adm9i/rative    
contractor1 ,m$ic>e ,advantage plan1 or 
prescription drug plan %all provide     
contract$ heal? c>e provid]s writt5     
notice ( ! new or am5d$ requirem5t or   
am5dm5t no less ?an #fj days be=e !     
requirem5t or re/riction is implem5t$ & 
%all ensure t ! new or am5d$ requirem5t 
has be5 updat$ on ! m$ic>e adm9i/rative 
contractor1 ,m$ic>e ,advantage plan1 or 
prescription drug plan's website4  7#g7 
,availability ( det]m9ations ,! m$ic>e  
adm9i/rative contractor1 ,m$ic>e        
,advantage plan1 or prescription drug   
plan1 respectively1 utiliz+             
preau?orization %all make /ati/ics      
available reg>d+ preau?orization        

approvals & d5ials = cov]age or paym5t (
 heal? c>e s]vices "u ! ,m$ic>e program 
"u title ,,xviii ( ! ,social ,security  
,act or su* plan on _! website 9 a      
readily accessible =mat4 ,! m$ic>e      
adm9i/rative contractor1 ,m$ic>e        
,advantage plan1 or prescription drug   
plan %all include categories =--  7,a7  
physician specialty2  7,b7 m$ication or 
diagno/ic te/_/proc$ure2  7,c7          
indication (f]$2 &  7,d7 reason = d5ial4
  7#h7 ,det]m9ations made by physicians 
,! m$ic>e adm9i/rative contractor1      
,m$ic>e ,advantage plan1 or prescription
 drug plan1 respectively1 %all ensure t 
all preau?orizations & adv]se           
det]m9ations are made by a physician :o 
possesses a curr5t & valid non-re/rict$ 
lic5se to practice m$ic9e 9 a ,/ate1 &  
mu/ be bo>d c]tifi$ or eligible 9 ! same
 specialty z ! heal? c>e provid] :o     
typically manages ! m$ical condition or 
disease or provides ! heal? c>e s]vice4 
,! physician mu/ make ! adv]se          
det]m9ation "u ! cl9ical direction ( "o 

( ! m$ic>e adm9i/rative contractor's1   
,m$ic>e ,advantage plan's1 or           
prescription drug plan's m$ical         
directors :o is responsible = !         
provision ( heal? c>e s]vices & :o is   
lic5s$ 9 su* ,/ate4