,i #aaith ,,congress #ast ,session ,h4 ,r4 #deei ,,in ,,the ,,house ,,of ,,representatives ,july #ba1 #bjbe,mr4 ,doggett 7for himself and ,mr4 ,murphy7 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 amend title ,,xviii of the ,social ,security ,act to establish payment parity between ,medicare ,advantage and fee-for-service ,medicare1 and to establish prompt payment requirements under ,medicare ,advantage4 #a4 ,short title ,this ,act may be cited as the ,prompt and ,fair ,pay ,act4 #b4 ,establishing payment parity between ,medicare ,advantage and fee-for-service ,medicare ,section #aheg7;e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;e77 is amended by adding at the end the following new paragraph3 7#f7 ,payment parity with fee-for-service ,medicare ,beginning with plan years beginning on or after ,january #a1 #bjbg1 a contract under this part shall require an ,,ma organization to provide1 in any contract between the organization and a provider or supplier1 that payment for items and services furnished to an enrollee by such provider or supplier shall be in an amount that is not less than the amount of payment applicable on the date of service for such items and services under the original ,medicare fee-for-service program under parts ,a and ,b1 including cost-based payment methodologies4 4 #c4 ,protecting beneficiary access to care under ,medicare ,advantage by establishing enforceable prompt payment requirements and enhancing transparency regarding claims denials 7a7 ,applying prompt payment requirements for items and services furnished by in-,network providers 7#a7 ,in general ,section #aheg7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;f77 is amended-- 7,a7 in paragraph 7#a71 in the header1 by inserting ,applicable with respect to out-of-network providers of services and suppliers after ,requirement2 7,b7 in paragraph 7#b71 by striking compliance with paragraph 7#a7 and inserting compliance with paragraph 7#a7 or 7#b72 7,c7 by redesignating paragraphs 7#b7 and 7#c7 as paragraphs 7#c7 and 7#d71 respectively2 and 7,d7 by inserting after paragraph 7#a7 the following new paragraph3 7#b7 ,requirement applicable with respect to in-network providers of services and suppliers 7,a7 ,prompt payment of clean claims 7i7 ,in general ,for contract years beginning on or after ,january #a1 #bjbg1 a contract entered into with an ,,ma organization with respect to offering an ,,ma plan under this part shall require that contracts and other agreements between such ,,ma organization and providers of services and suppliers to furnish items and services to enrollees under such plan shall provide that payment shall1 in accordance with the provisions of this paragraph1 be issued1 mailed1 or otherwise transmitted1 with respect to all clean claims submitted for such items and services furnished by such providers of services and suppliers to such enrollees1 by not later than the applicable number of calendar days 7as defined in clause 7iii77 after the date on which the claim is received 7as determined in accordance with clause 7ii774 7ii7 ,date of receipt of claim ,for purposes of this paragraph1 a claim is considered to have been received-- 7,i7 with respect to claims submitted electronically1 on the date on which the claim is transferred2 and 7,,ii7 with respect to claims submitted otherwise1 on the #eth day after the postmark date of the claim or the date specified in the time stamp of transmission4 7iii7 ,applicable number of calendar days defined ,for purposes of this paragraph1 the term applicable number of calendar days means-- 7,i7 with respect to claims submitted electronically1 #ad days2 and 7,,ii7 with respect to claims submitted otherwise1 #cj days4 7,b7 ,procedures and rules for determining whether claims are clean claims 7i7 ,clean claim defined ,in this paragraph1 the term clean claim means-- 7,i7 a claim that has no defect or impropriety 7including any lack of any required substantiating documentation7 or particular circumstance requiring special treatment that prevents timely payment from being made on the claim under this part2 and 7,,ii7 a claim that otherwise conforms to the clean claim requirements for equivalent claims under original ,medicare4 7ii7 ,claim deemed to be clean when timely notice of any deficiency is not provided ,for purposes of this paragraph1 with respect to an ,,ma organization and a provider of services or supplier with whom the ,,ma organization has a contract to furnish items and services1 a claim for such items and services furnished by such provider of services or supplier under such contract shall be deemed to be a clean claim if the ,,ma organization does not provide notice to the provider of services or supplier of any deficiency in the claim-- 7,i7 with respect to claims submitted electronically1 within #aj days after the date on which the claim is received2 and 7,,ii7 with respect to claims submitted otherwise1 within #ae days after the date on which the claim is received4 7iii7 ,required notifications and treatment of claims initially determined to not be clean claims ,for purposes of this paragraph1 with respect to an ,,ma organization and a provider of services or supplier with whom the ,,ma organization has a contract to furnish items and services-- 7,i7 if the ,,ma organization determines that a submitted claim for such items and services furnished by such provider of services or supplier under such contract is not a clean claim1 the ,,ma organization shall1 not later than the end of the applicable period described in clause 7ii71 notify the provider of services or supplier of such determination and in such notification shall specify all defects or improprieties in the claim and shall list all additional information or documents necessary for the proper processing and payment of the claim1 including detailed instructions for resubmission of claims1 how to address each specified defect or impropriety1 any formatting or coding guidance specific to the rejection reason1 and how to contact the plan to obtain assistance with resubmission2 and 7,,ii7 in the case in which additional information is received pursuant to a notification under subclause 7,i7 with respect to a claim described in such subclause1 the claim shall be deemed to be a clean claim described in clause 7i7 if the ,,ma organization does not provide notice to the provider of service or supplier of any defect or impropriety in the claim not later than #aj days of the date on which such additional information is received4 7iv7 ,rule of construction ,a determination under this paragraph that a claim submitted by a provider of services or supplier is a clean claim shall not be construed as a positive determination regarding eligibility for payment under this title1 nor is it an indication of government approval of1 or acquiescence regarding1 the claim submitted4 ,the determination shall not relieve any party of civil or criminal liability with respect to the claim1 nor does it offer a defense to any administrative1 civil1 or criminal action with respect to the claim4 7,c7 ,obligation to pay ,for purposes of this paragraph3 7i7 ,in general ,a claim submitted to an ,,ma organization that is not paid or contested by the organization within the applicable number of calendar days 7as defined in subparagraph 7,a77iii77 after the date on which the claim is received 7as determined in accordance with subparagraph 7,a77ii77 shall be deemed to be a clean claim and shall be paid by the ,,ma organization in accordance with subparagraph 7,a77i74 7ii7 ,electronic transfer of funds ,an ,,ma organization shall pay all clean claims submitted electronically by electronic transfer of funds if the provider of services or supplier so requests or has so requested previously4 ,in the case in which such payment is made electronically1 remittance may be made by the ,,ma organization electronically as well4 7iii7 ,date of payment of claim ,payment of a clean claim under this paragraph shall be considered to have been made on the date on which-- 7,i7 with respect to claims paid electronically1 the payment is transferred2 and 7,,ii7 with respect to claims paid otherwise1 the payment is submitted to the ,united ,states ,postal ,service or common carrier for delivery4 7,d7 ,interest payment 7i7 ,for purposes of this paragraph1 subject to clause 7ii71 if payment is not issued1 mailed1 or otherwise transmitted within the applicable number of calendar days 7as defined in subparagraph 7,a77iii77 after a clean claim 7with respect to which this paragraph applies7 is received1 the ,,ma organization shall pay interest to the provider of services or supplier that submitted the claim at a rate equal to the weighted average of interest on #c-month marketable ,treasury securities determined for such period1 increased by #j4a percentage point for the period beginning on the day after the required payment date and ending on the date on which payment is made 7as determined under subparagraph 7,c77iii774 ,interest amounts paid under this subparagraph shall not be counted against the administrative costs of an ,,ma plan for purposes of determining the medical loss ratio of the plan under subsection 7e77#d74 7ii7 ,authority not to charge interest ,the ,secretary may provide that an ,,ma organization is not charged interest under clause 7i7 in the case in which there are exigent circumstances1 including natural disasters and other unique and unexpected events1 that prevent the timely processing of claims4 7,e7 ,protecting the rights of claimants 7i7 ,in general ,nothing in this paragraph shall be construed to prohibit or limit a claim or action not covered by the subject matter of this paragraph that any individual or organization has against a provider of services1 supplier1 or an ,,ma organization4 7ii7 ,anti-retaliation ,consistent with applicable ,federal and ,state laws1 an ,,ma organization shall not retaliate against an individual1 provider of services1 or supplier for exercising a right of action under this subparagraph4 4 7#b7 ,secretarial authority to enforce prompt payment requirement ,section #aheg7;g77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;g77#a77 is amended-- 7,a7 in subparagraph 7,j71 by striking at the end or2 7,b7 in subparagraph 7,k71 by inserting or after the semicolon2 and 7,c7 by inserting after subparagraph 7,k7 the following new subparagraph3 7,l7 fails to comply with the provisions of subsection 7f77#b72 4