,i #aai? ,,congress #a/ ,session ,h4 ,r4 #deei ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,july #ba1 #bjbe,mr4 ,doggett 7= himself & ,mr4 ,murphy7 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 am5d title ,,xviii ( ! ,social ,security ,act to e/abli% paym5t p>ity betwe5 ,m$ic>e ,advantage & fee-=-s]vice ,m$ic>e1 & to e/abli% prompt paym5t requirem5ts "u ,m$ic>e ,advantage4 #a4 ,%ort title ,?is ,act may be cit$ z ! ,prompt & ,fair ,pay ,act4 #b4 ,e/abli%+ paym5t p>ity betwe5 ,m$ic>e ,advantage & fee-=-s]vice ,m$ic>e ,section #aheg7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;e77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#f7 ,paym5t p>ity ) fee-=-s]vice ,m$ic>e ,beg9n+ ) plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbg1 a contract "u ?is "p %all require an ,,ma organization to provide1 9 any contract betwe5 ! organization & a provid] or suppli]1 t paym5t = items & s]vices furni%$ to an enrollee by su* provid] or suppli] %all be 9 an am\nt t is n less ?an ! am\nt ( paym5t applicable on ! date ( s]vice = su* items & s]vices "u ! orig9al ,m$ic>e fee-=-s]vice program "u p>ts ,a & ,b1 includ+ co/-bas$ paym5t me?odologies4 4 #c4 ,protect+ b5efici>y access to c>e "u ,m$ic>e ,advantage by e/abli%+ en=ceable prompt paym5t requirem5ts & enhanc+ transp>5cy reg>d+ claims d5ials 7a7 ,apply+ prompt paym5t requirem5ts = items & s]vices furni%$ by 9-,network provid]s 7#a7 ,9 g5]al ,section #aheg7;f7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;f77 is am5d$-- 7,a7 9 p>agraph 7#a71 9 ! head]1 by ins]t+ ,applicable ) respect to out-(-network provid]s ( s]vices & suppli]s aft] ,requirem5t2 7,b7 9 p>agraph 7#b71 by /rik+ compliance ) p>agraph 7#a7 & ins]t+ compliance ) p>agraph 7#a7 or 7#b72 7,c7 by r$esignat+ p>agraphs 7#b7 & 7#c7 z p>agraphs 7#c7 & 7#d71 respectively2 & 7,d7 by ins]t+ aft] p>agraph 7#a7 ! foll[+ new p>agraph3 7#b7 ,requirem5t applicable ) respect to 9-network provid]s ( s]vices & suppli]s 7,a7 ,prompt paym5t ( clean claims 7i7 ,9 g5]al ,= contract ye>s beg9n+ on or aft] ,janu>y #a1 #bjbg1 a contract ent]$ into ) an ,,ma organization ) respect to (f]+ an ,,ma plan "u ?is "p %all require t contracts & o!r agreem5ts betwe5 su* ,,ma organization & provid]s ( s]vices & suppli]s to furni% items & s]vices to enrollees "u su* plan %all provide t paym5t %all1 9 accordance ) ! provisions ( ?is p>agraph1 be issu$1 mail$1 or o!rwise transmitt$1 ) respect to all clean claims submitt$ = su* items & s]vices furni%$ by su* provid]s ( s]vices & suppli]s to su* enrollees1 by n lat] ?an ! applicable numb] ( cal5d> days 7z def9$ 9 clause 7iii77 aft] ! date on :i* ! claim is receiv$ 7z det]m9$ 9 accordance ) clause 7ii774 7ii7 ,date ( receipt ( claim ,= purposes ( ?is p>agraph1 a claim is consid]$ to h be5 receiv$-- 7,i7 ) respect to claims submitt$ electronically1 on ! date on :i* ! claim is transf]r$2 & 7,,ii7 ) respect to claims submitt$ o!rwise1 on ! #e? day aft] ! po/m>k date ( ! claim or ! date specifi$ 9 ! "t /amp ( transmission4 7iii7 ,applicable numb] ( cal5d> days def9$ ,= purposes ( ?is p>agraph1 ! t]m applicable numb] ( cal5d> days means-- 7,i7 ) respect to claims submitt$ electronically1 #ad days2 & 7,,ii7 ) respect to claims submitt$ o!rwise1 #cj days4 7,b7 ,proc$ures & rules = det]m9+ :e!r claims are clean claims 7i7 ,clean claim def9$ ,9 ?is p>agraph1 ! t]m clean claim means-- 7,i7 a claim t has no defect or impropriety 7includ+ any lack ( any requir$ sub/antiat+ docum5tation7 or p>ticul> circum/ance requir+ special treatm5t t prev5ts timely paym5t f be+ made on ! claim "u ?is "p2 & 7,,ii7 a claim t o!rwise con=ms to ! clean claim requirem5ts = equival5t claims "u orig9al ,m$ic>e4 7ii7 ,claim deem$ to be clean :5 timely notice ( any defici5cy is n provid$ ,= purposes ( ?is p>agraph1 ) respect to an ,,ma organization & a provid] ( s]vices or suppli] ) :om ! ,,ma organization has a contract to furni% items & s]vices1 a claim = su* items & s]vices furni%$ by su* provid] ( s]vices or suppli] "u su* contract %all be deem$ to be a clean claim if ! ,,ma organization does n provide notice to ! provid] ( s]vices or suppli] ( any defici5cy 9 ! claim-- 7,i7 ) respect to claims submitt$ electronically1 )9 #aj days aft] ! date on :i* ! claim is receiv$2 & 7,,ii7 ) respect to claims submitt$ o!rwise1 )9 #ae days aft] ! date on :i* ! claim is receiv$4 7iii7 ,requir$ notifications & treatm5t ( claims initially det]m9$ to n be clean claims ,= purposes ( ?is p>agraph1 ) respect to an ,,ma organization & a provid] ( s]vices or suppli] ) :om ! ,,ma organization has a contract to furni% items & s]vices-- 7,i7 if ! ,,ma organization det]m9es t a submitt$ claim = su* items & s]vices furni%$ by su* provid] ( s]vices or suppli] "u su* contract is n a clean claim1 ! ,,ma organization %all1 n lat] ?an ! end ( ! applicable p]iod describ$ 9 clause 7ii71 notify ! provid] ( s]vices or suppli] ( su* det]m9ation & 9 su* notification %all specify all defects or improprieties 9 ! claim & %all li/ all additional in=mation or docum5ts necess>y = ! prop] process+ & paym5t ( ! claim1 includ+ detail$ in/ructions = resubmission ( claims1 h[ to address ea* specifi$ defect or impropriety1 any =matt+ or cod+ guidance specific to ! rejection reason1 & h[ to contact ! plan to obta9 assi/ance ) resubmission2 & 7,,ii7 9 ! case 9 :i* additional in=mation is receiv$ pursuant to a notification "u subclause 7,i7 ) respect to a claim describ$ 9 su* subclause1 ! claim %all be deem$ to be a clean claim describ$ 9 clause 7i7 if ! ,,ma organization does n provide notice to ! provid] ( s]vice or suppli] ( any defect or impropriety 9 ! claim n lat] ?an #aj days ( ! date on :i* su* additional in=mation is receiv$4 7iv7 ,rule ( con/ruction ,a det]m9ation "u ?is p>agraph t a claim submitt$ by a provid] ( s]vices or suppli] is a clean claim %all n be con/ru$ z a positive det]m9ation reg>d+ eligibility = paym5t "u ?is title1 nor is x an indication ( gov]nm5t approval (1 or acquiesc5ce reg>d+1 ! claim submitt$4 ,! det]m9ation %all n relieve any p>ty ( civil or crim9al liability ) respect to ! claim1 nor does x (f] a def5se to any adm9i/rative1 civil1 or crim9al action ) respect to ! claim4 7,c7 ,obligation to pay ,= purposes ( ?is p>agraph3 7i7 ,9 g5]al ,a claim submitt$ to an ,,ma organization t is n paid or conte/$ by ! organization )9 ! applicable numb] ( cal5d> days 7z def9$ 9 subp>agraph 7,a77iii77 aft] ! date on :i* ! claim is receiv$ 7z det]m9$ 9 accordance ) subp>agraph 7,a77ii77 %all be deem$ to be a clean claim & %all be paid by ! ,,ma organization 9 accordance ) subp>agraph 7,a77i74 7ii7 ,electronic transf] ( funds ,an ,,ma organization %all pay all clean claims submitt$ electronically by electronic transf] ( funds if ! provid] ( s]vices or suppli] s reque/s or has s reque/$ previ\sly4 ,9 ! case 9 :i* su* paym5t is made electronically1 remittance may be made by ! ,,ma organization electronically z well4 7iii7 ,date ( paym5t ( claim ,paym5t ( a clean claim "u ?is p>agraph %all be consid]$ to h be5 made on ! date on :i*-- 7,i7 ) respect to claims paid electronically1 ! paym5t is transf]r$2 & 7,,ii7 ) respect to claims paid o!rwise1 ! paym5t is submitt$ to ! ,unit$ ,/ates ,po/al ,s]vice or common c>ri] = deliv]y4 7,d7 ,int]e/ paym5t 7i7 ,= purposes ( ?is p>agraph1 subject to clause 7ii71 if paym5t is n issu$1 mail$1 or o!rwise transmitt$ )9 ! applicable numb] ( cal5d> days 7z def9$ 9 subp>agraph 7,a77iii77 aft] a clean claim 7) respect to :i* ?is p>agraph applies7 is receiv$1 ! ,,ma organization %all pay int]e/ to ! provid] ( s]vices or suppli] t submitt$ ! claim at a rate equal to ! weight$ av]age ( int]e/ on #c-mon? m>ketable ,treasury securities det]m9$ = su* p]iod1 increas$ by #j4a p]c5tage po9t = ! p]iod beg9n+ on ! day aft] ! requir$ paym5t date & end+ on ! date on :i* paym5t is made 7z det]m9$ "u subp>agraph 7,c77iii774 ,int]e/ am\nts paid "u ?is subp>agraph %all n be c\nt$ aga9/ ! adm9i/rative co/s ( an ,,ma plan = purposes ( det]m9+ ! m$ical loss ratio ( ! plan "u subsection 7e77#d74 7ii7 ,au?ority n to *>ge int]e/ ,! ,secret>y may provide t an ,,ma organization is n *>g$ int]e/ "u clause 7i7 9 ! case 9 :i* !re are exig5t circum/ances1 includ+ natural disa/]s & o!r unique & unexpect$ ev5ts1 t prev5t ! timely process+ ( claims4 7,e7 ,protect+ ! rights ( claimants 7i7 ,9 g5]al ,no?+ 9 ?is p>agraph %all be con/ru$ to prohibit or limit a claim or action n cov]$ by ! subject matt] ( ?is p>agraph t any individual or organization has aga9/ a provid] ( s]vices1 suppli]1 or an ,,ma organization4 7ii7 ,anti-retaliation ,consi/5t ) applicable ,f$]al & ,/ate laws1 an ,,ma organization %all n retaliate aga9/ an individual1 provid] ( s]vices1 or suppli] = ex]cis+ a "r ( action "u ?is subp>agraph4 4 7#b7 ,secret>ial au?ority to en=ce prompt paym5t requirem5t ,section #aheg7;g77#a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#bg7;g77#a77 is am5d$-- 7,a7 9 subp>agraph 7,j71 by /rik+ at ! end or2 7,b7 9 subp>agraph 7,k71 by ins]t+ or aft] ! semicolon2 & 7,c7 by ins]t+ aft] subp>agraph 7,k7 ! foll[+ new subp>agraph3 7,l7 fails to comply ) ! provisions ( subsection 7f77#b72 4