,i  #aai? ,,congress  #b;d ,session  ,h4
 ,r4 #hcge  ,,9 ,,! ,,h\se ,,(          
,,repres5tatives  ,april #bj1 #bjbf,mr4 
,joyce ( ,p5nsylvania 7= himself1 ,ms4  
,s*ri]1 ,mr4 ,murphy1 ,mr4 ,panetta1    
,mrs4 ,mill]-,meeks1 ,mr4 ,b]a1 & ,ms4  
,van ,duyne7 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   
provide = c]ta9 re=ms "u ! ,m$ic>e      
,advantage program1 & = o!r purposes4   
#a4 ,%ort title ,?is ,act may be cit$ z 
! ,m$ic>e ,advantage ,improvem5t ,act ( 
#bjbf4  #b4 ,improv+ access to timely   
c>e = enrollees ( ,m$ic>e ,advantage    
plans  7a7 ,r$uc+ timeframes = ,m$ic>e  
,advantage organizations ,to respond to 
c]ta9 au?orization reque/s  7#a7 ,/&>d  
organization det]m9ations ,section      

#aheb7;g77#a7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciew-#bb7;g77#a77 is  
am5d$--  7,a7 9 subp>agraph 7,a71 9 !   
second s5t5ce1 by ins]t+ subp>agraph    
7,c7 & aft] ,subject to2  7,b7 9        
subp>agraph 7,b71 by /rik+ ,su* a       
det]m9ation & ins]t+ ,a det]m9ation     
describ$ 9 subp>agraph 7,a7 or 7,c72 &  
7,c7 by add+ at ! end ! foll[+ new      
subp>agraph3  7,c7 ,requir$ timeframes =
 responses to c]ta9 au?orization reque/s
  7i7 ,9 g5]al ,subject to clause 7ii7 &
 p>agraph 7#c77;,b77iii71 ! proc$ure    
e/abli%$ pursuant to subp>agraph 7,a7 by
 a ,m$ic>e ,advantage organization (f]+ 
an ,,ma plan %all provide t 9 ! case ( a
 reque/ made on or aft] ,janu>y #a1     
#bjbh1 = a specifi$ au?orization 7z     
def9$ 9 clause 7iii77 ) respect to an   
individual enroll$ "u su* plan1 !       
,m$ic>e ,advantage organization mu/     
notify ! individual 7& ! provid] (      
s]vices or suppli] involv$1 z           
appropriate7 ( ! det]m9ation reg>d+ su* 
reque/ z exp$iti\sly z ! heal? condition

 ( ! individual requires1 b1 subject to 
clause 7iv71 n lat] ?an #gb h\rs aft]   
receipt ( ! reque/4  7ii7  ,ext5sions   
,subject to clause 7iv71 a ,m$ic>e      
,advantage organization (f]+ an ,,ma    
plan may ext5d ! deadl9e appli$ "u      
clause 7i7 or ! deadl9e appli$ "u       
p>agraph 7#c77;,b77iii77,,ii71 z        
applicable1 ) respect to a det]m9ation  
reg>d+ a specifi$ reque/ = an individual
 enroll$ "u ! ,,ma plan1 by up to #g    
cal5d> days if--  7,i7 ! individual     
reque/s ! ext5sion2  7,,ii7 ! ext5sion  
is ne$$ = purposes ( obta9+ additional  
relevant m$ical evid5ce f a provid] (   
s]vices or suppli] t does n h a contract
 ) ! ,,ma organization to furni% items &
 s]vices to individuals enroll$ "u !    
,,ma plan2 or  7,,iii7 ! ext5sion is 9 !
 individual's int]e/ & is ju/ifi$ by    
reason ( extraord9>y1 exig5t1 or o!r    
nonr\t9e circum/ances t are n )9 !      
reasonable control ( ! ,,ma organization
 7z det]m9$ by ! ,secret>y74  7iii7     
,specifi$ au?orization def9$  ,=        

purposes ( ?is "p1 ! t]m specifi$       
au?orization--  7,i7 means1 ) respect to
 an individual enroll$ "u an ,,ma plan  
(f]$ by a ,m$ic>e ,advantage            
organization1 an au?orization ( cov]age 
or paym5t = an item or s]vice ?r\gh--   
7aa7 a prior au?orization or pres]vice  
det]m9ation ( cov]age or paym5t2 or     
7bb7 a concurr5t det]m9ation made :ile !
 individual is receiv+ ! relevant item  
or s]vice2 &  7,,ii7 includes an        
au?orization = a transf] ( ! individual 
betwe5 hospitals or betwe5 a hospital & 
po/-acute c>e facility4  7iv7           
,secret>ial au?ority  ,) respect to     
reque/s = a specifi$ au?orization made  
on or aft] ,janu>y #a1 #bjcj1 9 c>ry+   
out clause 7i7 & 7ii7 & p>agraph        
7#c77;,b77iii77,,ii71 ! ,secret>y may   
specify ?r\gh notice & comm5t rulemak+ a
 deadl9e o!r ?an ! deadl9e specifi$ 9 ! 
relevant clause or p>agraph4  4  7#b7   
,exp$it$ organization det]m9ations      
,section #aheb7;g77#c77;,b77iii7 ( !    
,social ,security ,act 7#db ,u4,s4,c4   

#aciew-#bb7;g77#c77;,b77iii77 is am5d$--
  7,a7 by /rik+ ,timely response4--,9   
cases describ$ & ins]t+3  ,timely       
reponse4--  7,i7  ,9 g5]al  ,subject to 
subclause 7,,ii71 9 cases describ$  2 & 
7,b7 by add+ at ! end ! foll[+ new      
subclause3  7,,ii7 ,r$uc+ exp$it$       
timeframes = responses to c]ta9         
au?orization reque/s ,subject to        
p>agraph 7#a77;,c77ii71 9 cases describ$
 9 clauses 7i7 & 7ii7 t are relat$ to an
 exp$it$ det]m9ation = a specifi$       
au?orization 7z def9$ 9 p>agraph        
7#a77;,c77iii77 = :i* a reque/ is       
submitt$ on or aft] ,janu>y #a1 #bjbh1 !
 ,m$ic>e ,advantage organization %all   
notify ! enrollee 7& ! physician        
involv$1 z appropriate7 ( ! det]m9ation 
"u "t limitations e/abli%$ by !         
,secret>y4 ,subject to p>agraph         
7#a77;,c77iv71 su* notification %all be 
made n lat] ?an #bd h\rs aft] ! receipt 
( ! reque/ = ! det]m9ation 7or receipt (
 ! in=mation necess>y to make !         
det]m9ation74  4  7#c7  ,improv$        

transp>5cy ( c]ta9 prior au?orization   
in=mation on ! ,,ma plan level  ,beg9n+ 
) plan ye>s beg9n+ on or aft] ,janu>y   
#a1 #bjbh1 9 c>ry+ out ! provisions (   
section #dbb4abb7;c7 ( title #db1 ,code 
( ,f$]al ,regulations 7or any successor 
regulation71 ! ,secret>y ( ,heal? &     
,human ,s]vices %all--  7,a7 require    
,m$ic>e ,advantage organizations to     
report prior au?orization data describ$ 
9 su* section on ! plan level & on !    
,m$ic>e ,advantage organization p>5t    
level 9 addition to ! contract level2   
7,b7 require ,m$ic>e ,advantage         
organizations to report prior           
au?orization data describ$ 9 su* section
 9 a mann] t all[s comp>ison ( su* data 
bas$ on provid] & s]vice category2 &    
7,c7 9 addition to mak+ su* data        
publicly available1 z describ$ 9 su*    
section1 make su* data available 9 a    
d[nloadable =mat t is accessible =      
rese>* purposes & ov]sight & en=cem5t   
activities ( ! ,secret>y4  7b7          
,real-,"t au?orization decisions = c]ta9

 id5tifi$ s]vices  ,section             
#aheb7;g77#a7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciew-#bb7;g77#a771 z  
am5d$ by subsection 7a71 is fur!r       
am5d$--  7#a7 9 subp>agraph 7,a71 9 !   
second s5t5ce1 by /rik+ subp>agraph 7,c7
 & & ins]t+ subp>agraphs 7,c7 & 7,d7 &2 
7#b7 9 subp>agraph 7,b71 by /rik+ ,a    
det]m9ation describ$ 9 subp>agraph 7,a7 
or 7,c7 & ins]t+ ,a det]m9ation describ$
 9 subp>agraph 7,a71 7,c71 or 7,d72     
7#c7 9 subp>agraph 7,c77i71 by /rik+    
,subject to clause 7ii7 & ins]t+        
,subject to clause 7ii71 subp>agraph    
7,d712 &  7#d7 by add+ at ! end ! foll[+
 new subp>agraph3  7,d7 ,real-"t        
au?orization decisions = id5tifi$       
s]vices  7i7 ,9 g5]al ,! proc$ure       
e/abli%$ pursuant to subp>agraph 7,a7   
%all require t ! ,m$ic>e ,advantage     
organization has 9 place a me*anism &   
process ?r\gh :i*1 beg9n+ ,janu>y #a1   
#bjbh1 ! organization provides a real-"t
 det]m9ation1 9 accordance ) ?is        
subp>agraph1 9 response to any reque/ = 

a specifi$ au?orization 7z def9$ 9      
subp>agraph 7,c77iii77 t is--  7,i7 made
 ) respect to an item or s]vice id5tifi$
 on ! mo/ rec5t li/ publi%$ pursuant to 
clause 7iii72 &  7,,ii7 submitt$ ?r\gh  
c]tifi$ ,,ehr te*nology 7z def9$ 9      
section #ahdh7o77#d774  7ii7            
,requirem5ts = real-"t me*anism &       
process  ,! me*anism & process requir$  
"u clause 7i7 %all-- 7,i7 include       
real-"t tools capable ( provid+ imm$iate
 automat$ approvals2  7,,ii7 provide = !
 integration ( su* tools 9 a mann] t is 
int]op]able ) c]tifi$ ,,ehr te*nology 7z
 s def9$7 us$ by provid]s ( s]vices &   
suppli]s2 &  7,,iii7 enable imm$iate    
notification to ! provid] ( s]vices or  
suppli]1 z applicable1 ( det]m9ations1  
includ+1 9 ! case ( a d5ial1            
notification ( any additional           
docum5tation ne$$4  7iii7  ,annual      
publication ( li/ ( id5tifi$ s]vices    
requir+ real-"t au?orization support  ,=
 purposes ( ?is subp>agraph1 = ea* plan 
ye> beg9n+ on or aft] ,janu>y #a1 #bjbh1

 ! ,secret>y %all annually e/abli% ?r\gh
 notice & comm5t rulemak+ a li/ id5tify+
 ! foll[+ items & s]vices3  7,i7 ,items 
& s]vices = :i*1 ) respect to ! previ\s 
plan ye>1 at lea/ #ij p]c5t ( reque/s = 
a specifi$ au?orization 7 approv$ across
 all ,m$ic>e ,advantage organizations4  
7,,ii7 ,items & s]vices t are cl9ically 
l[-risk & r\t9e1 z def9$ by ! ,secret>y 
?r\gh notice & comm5t rulemak+4  7,,iii7
 ,items & s]vices t ! ,secret>y         
id5tifies1 accord+ to /&>ds specifi$ by 
! ,secret>y ?r\gh notice & comm5t       
rulemak+1 z repres5tative ( significant 
s]vice volume & adm9i/rative burd5 =    
acquir+ su* a specifi$ au?orization4    
7iv7  ,improv+ transp>5cy  7,i7         
,qu>t]ly ,,mao reports to ,,cms  ,beg9n+
 ,janu>y #a1 #bjbh1 & qu>t]ly !reaft]1  
ea* ,m$ic>e ,advantage organization (f]+
 an ,,ma plan %all submit to ! ,secret>y
 79 a =m & mann] specifi$ by !          
,secret>y7 in=mation 7pres5t$ by provid]
 & s]vice type7 reg>d+ real-"t          
det]m9ations made by ! organization dur+

 ! previ\s qu>t] pursuant to ?is        
subp>agraph1 includ+ in=mation on--     
7aa7 ! numb] ( real-"t det]m9ations made
 dur+ ! qu>t]1 & ! p]c5tage ( all       
det]m9ations made dur+ ! qu>t] ) respect
 to an item or s]vice id5tifi$ on ! mo/ 
rec5t li/ publi%$ pursuant to clause    
7iii7 t 7 real-"t det]m9ations2  7bb7 ! 
numb] & p]c5tage ( real-"t det]m9ations 
made dur+ su* qu>t] t 7 approv$2  7cc7 !
 numb] & p]c5tage ( su* det]m9ations t 7
 d5i$2  7dd7 ! numb] & p]c5tage ( su*   
d5i$ det]m9ations t 7 appeal$2  7ee7 !  
numb] & p]c5tage ( su* appeal$          
det]m9ations t 7 ov]turn$2 &  7ff7 !    
numb] & p]c5tage ( provid] compla9ts    
reg>d+ ! me*anism & process implem5t$ by
 ! ,m$ic>e ,advantage organization      
pursuant to ?is subp>agraph4  ,!        
in=mation submitt$ pursuant to ! previ\s
 s5t5ce %all include su* in=mation & be 
provid$ 9 su* a mann] to enable         
comp>ison & analysis ( su* in=mation on 
! ,m$ic>e ,advantage organization level1
 ,m$ic>e ,advantage p>5t organization   

level1 & ,,ma plan level4  7,,ii7       
,public availability ( in=mation  ,!    
,secret>y %all make in=mation collect$  
"u subclause 7,i7 publicly available on 
! int]net website ( ! ,c5t]s = ,m$ic>e  
,m$icaid ,s]vices4  4  7c7 ,prohibit+   
c]ta9 au?orization processes = c]ta9    
cl9ically necess>y *anges & ext5sions   
,section #aheb7;d7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #aciew-#bb7;d77 is 
am5d$ by add+ at ! end ! foll[+ new     
p>agraph3  7#g7 ,prohibition on requir+ 
c]ta9 au?orizations ,beg9n+ ,janu>y #a1 
#bjbh1 9 ! case t a ,m$ic>e ,advantage  
organization (f]+ an ,,ma plan provides 
approval ?r\gh a specifi$ au?orization  
7z def9$ 9 subsection 7g77#a77;,c77iii77
 = an item or s]vice to be furni%$ to an
 individual enroll$ 9 ! plan by a       
provid] ( s]vices or suppli]1 if dur+ ! 
c\rse ( furni%+ su* approv$ item or     
s]vice ! provid] ( s]vices or suppli]   
det]m9es t a modification1 ext5sion1 or 
adju/m5t to su* item or s]vice is       
cl9ically necess>y1 ! ,m$ic>e ,advantage

 organization may n require a specifi$  
au?orization 7z def9$ 9 subsection      
7g77#a77;,c77iii77 to be reque/$ )      
respect to su* item or s]vice z s       
modifi$1 ext5d$1 or adju/$4 ,application
 ( ! previ\s s5t5ce %all n limit !      
au?ority ( ! ,m$ic>e ,advantage         
organization to require docum5tation or 
po/-s]vice notification ( any su*       
modification1 ext5sion1 or adju/m5t4  4 
7d7 ,improvem5ts to ! reconsid]ations   
process ,section #aheb7;g7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4           
#aciew-#bb7;g77 is am5d$-- 7#a7 9       
p>agraph 7#b7--  7,a7 9 subp>agraph     
7,a71 by ins]t+ 7or1 ) respect to       
det]m9ations made on or aft] ,janu>y #a1
 #bjbh1 n lat] ?an #ad days7 aft] #fj   
days2 &  7,b7 by add+ at ! end ! foll[+ 
new subp>agraph3  7,c7  ,reconsid]ations
 affirm+ d5ials ( cov]age  ,if a        
reconsid]ation affirms 79 :ole or 9 "p7 
a d5ial ( cov]age 7includ+ an adv]se    
organization det]m9ation "u section     
#dbb4eij ( title #db1 ,code ( ,f$]al    

,regulations1 or any successor          
regulation7 made on or aft] ,janu>y #a1 
#bjbh1 ) respect to an individual       
enroll$ 9 an ,,ma plan (f]$ by a ,m$ic>e
 ,advantage organization1 ! ,m$ic>e     
,advantage organization %all submit to !
 indep5d5t1 outside entity ) a contract 
"u p>agraph 7#d7 ! case file & writt5   
explanation ( ! decision z exp$iti\sly z
 ! individual's heal? condition         
requires1 b n lat] ?an #ad days aft] !  
date ! ,m$ic>e ,advantage organization  
receiv$ ! reque/ = ! reconsid]ation4  2 
&  7#b7 9 p>agraph 7#d7-- 7,a7 by /rik+ 
cov]age d5ials4--,! ,secret>y %all      
contract ) & ins]t+3  cov]age d5ials4-- 
7,a7 ,9 g5]al ,! ,secret>y %all contract
 )  2 &  7,b7 by add+ at ! end ! foll[+ 
new subp>agraphs3  7,b7 ,requirem5ts ,9 
review+ & resolv+ pursuant to           
subp>agraph 7,a7 a reconsid]ation ( a   
det]m9ation ( a ,m$ic>e ,advantage      
organization made on or aft] ,janu>y #a1
 #bjbh1 ) respect to an individual      
enroll$ 9 an ,,ma plan (f]$ by !        

organization1 ! indep5d5t1 outside      
entity %all comply ) ea* ( ! foll[+     
requirem5ts3  7i7 ,notice & opportunity 
to provide support+ docum5tation ,!     
entity %all-- 7,i7 n lat] ?an #c days   
aft] ! date ( receipt ( ! relevant case 
file f ! ,m$ic>e ,advantage             
organization1 submit to ! individual1 ! 
repres5tative ( ! individual 7if        
applicable71 & ! provid] ( s]vices or   
suppli] furni%+ 7or ord]+7 ! item or    
s]vice t is ! subject ( ! det]m9ation1 a
 notification reg>d+ ! opportunity to   
submit docum5tation1 includ+ m$ical     
records1 reg>d+ m$ical necessity2 &     
7,,ii7 provide a p]iod ( #g days f !    
date ( receipt ( su* notification =     
submission ( any su* docum5tation4  7ii7
 ,decision timeframe ,aft] review+ &    
consid]+ all support+ docum5tation      
receiv$ be=e ! end ( ! #g-;day p]iod    
describ$ 9 clause 7i77,,ii71 ! entity   
%all issue its decision ) respect to su*
 reconsid]ation z exp$iti\sly z !       
individual's heal? condition requires1 b

 by n lat] ?an ! applicable numb] ( days
 specifi$ 9 subp>agraph 7,c7 aft] ! la/ 
day ( ! #g-;day p]iod describ$ 9 clause 
7i77,,ii74  7,c7 ,applicable numb] (    
days ,= purposes ( subp>agraph 7,b77ii71
 ! applicable numb] ( days specifi$ 9   
?is subp>agraph is-- 7i7 #ad days1 9 !  
case ( a reque/ 7o!r ?an ) respect to an
 exp$it$ reconsid]ation "u p>agraph     
7#c77 = cov]age ( an item or s]vice t is
 n a drug = :i* paym5t may be made "u "p
 ,b2  7ii7 #g days1 9 ! case ( a reque/ 
7o!r ?an ) respect to an exp$it$        
reconsid]ation "u p>agraph 7#c77 =      
cov]age ( a drug = :i* paym5t may be    
made "u "p ,b2  7iii7 #cj days1 9 ! case
 ( a reque/ 7o!r ?an ) respect to an    
exp$it$ reconsid]ation "u p>agraph 7#c77
 = paym5t ( an item or s]vice2 &  7iv7  
#bd h\rs1 9 ! case ( a reque/ ) respect 
to an exp$it$ reconsid]ation "u p>agraph
 7#c74  4  #c4 ,ensur+ appropriate      
ov]sight ( ,m$ic>e ,advantage plans  7a7
 ,,mao compliance scor+ & acc\ntability 
program ,section #ahec ( ! ,social      

,security ,act 7#db ,u4,s4,c4           
#aciew-#bc7 is am5d$ by add+ at ! end ! 
foll[+ new subsection3  7p7 ,compliance 
scor+ & en=cem5t  7#a7 ,paym5t r$uctions
 = ,m,a,os 9 noncompliance ) c]ta9 ,,ma 
program requirem5ts  7,a7 ,9 g5]al ,9 ! 
case ( a ,m$ic>e ,advantage organization
 ) a contract "u ?is "p t ! ,secret>y   
det]m9es1 9 accordance ) ?is subsection1
 to be )9 a compliance ti] specifi$ 9   
subp>agraph 7,b7 = a p]=mance p]iod )   
respect to a plan ye> beg9n+ on or aft] 
,janu>y #a1 #bjbh1 ! ,secret>y %all     
r$uce ! total ( ! mon?ly paym5ts made = 
! plan ye> "u section #ahec7;a77#a7 to !
 ,m$ic>e ,advantage organization )      
respect to ea* ,m$ic>e ,advantage plan  
(f]$ by su* organization by ! applicable
 p]c5t specifi$ "u subp>agraph 7,b7 )   
respect to ! compliance ti]4  7,b7      
,applicable p]c5t specifi$ ,= purposes (
 subp>agraph 7,a71 ! applicable p]c5t   
specifi$ "u ?is subp>agraph is z foll[s3
  7i7 ,) respect to ! compliance ti]    
describ$ 9 p>agraph 7#e77;,b71 #a4j     

p]c5t4  7ii7 ,) respect to ! compliance 
ti] describ$ 9 p>agraph 7#e77;,c71 #a4e 
p]c5t4  7iii7 ,) respect to ! compliance
 ti] describ$ 9 p>agraph 7#e77;,d71 #b4j
 p]c5t4  7,c7 ,p]=mance p]iod ,=        
purposes ( ?is subsection1 ! ,secret>y  
%all e/abli% a p]=mance p]iod 7or       
p]iods7 = ea* plan ye> beg9n+ on or aft]
 ,janu>y #a1 #bjbh4 ,su* p]=mance p]iod 
7or p]iods7 %all beg9 & end prior to !  
beg9n+ ( ! plan ye> & be z close z      
possible to su* plan ye>4 ,9 ?is        
subsection1 su* p]=mance p]iod 7or      
p]iods7 = a plan ye> %all be ref]r$ to z
 ! p]=mance p]iod ) respect to ! plan   
ye>4  7#b7 ,e/abli%m5t ( compliance     
scor+ & acc\ntability program ,=        
purposes ( ?is subsection1 ! ,secret>y  
%all e/abli% a ,m$ic>e ,advantage       
organization compliance scor+ &         
acc\ntability program 7ref]r$ to "u ?is 
subsection z ! ,,mao ,compliance        
,program7 "u :i*1 = ea* ,m$ic>e         
,advantage organization ) a contract "u 
?is "p & ea* p]=mance p]iod ) respect to

 a plan ye> beg9n+ on or aft] ,janu>y   
#a1 #bjbh1 ! ,secret>y-- 7,a7 us+ !     
me?od e/abli%$ "u p>agraph 7#c77;,a71   
%all assess ! ext5t to :i* ! ,m$ic>e    
,advantage organization is 9 compliance 
) requirem5ts "u ?is "p applicable to   
ea* compliance category specifi$ "u     
p>agraph 7#c77;,b72  7,b7 bas$ on su*   
assessm5ts = ea* su* compliance         
category1 %all assign a total compliance
 score to ! ,m$ic>e ,advantage          
organization1 9 accordance ) p>agraph   
7#d72 &  7,c7 bas$ on su* total         
compliance score1 %all assign ! ,m$ic>e 
,advantage organization to a compliance 
ti] describ$ 9 p>agraph 7#e74  7#c7     
,assessm5t me?od  7,a7 ,9 g5]al ,"u !   
,,mao ,compliance ,program1 ! ,secret>y 
%all e/abli% ?r\gh notice & comm5t      
rulemak+ a me?od to assess1 at ! plan   
level1 ! ext5t to :i* ea* ,m$ic>e       
,advantage organization (f]+ a ,m$ic>e  
,advantage plan is 9 compliance )       
requirem5ts "u ?is "p applicable to ea* 
compliance category specifi$ 9          

subp>agraph 7,b74 ,su* me?od %all       
include ! use ( audit me*anisms1 report+
 requirem5ts1 p]=mance measures e/abli%$
 or id5tifi$ by ! ,secret>y 7su* z      
applicable measures "u ! ,,ma ,program  
,compliance & ,cov]age ,protection      
,doma9 describ$ 9 section #ahec7o77#h771
 & su* o!r me?ods z specifi$ by !       
,secret>y4  7,b7 ,compliance categories 
7i7 ,9 g5]al ,subject to clause 7ii71 "u
 ! ,,mao ,compliance ,program1 ea* ( !  
foll[+ %all be a compliance category3   
7,i7 ,compliance ) timely & real-"t     
specifi$ au?orization decision-mak+     
requirem5ts1 includ+ compliance )       
section #aheb7;d77#g7 & p>agraphs       
7#a77;,c71 7#a77;,d71 &                 
7#c77;,b77iii77,,ii7 ( section          
#aheb7;g74  7,,ii7 ,compliance ) cov]age
 crit]ia /&>ds1 includ+ ! requirem5ts "u
 section #aheb7;g77#g7 & section        
#aheb7;a77#b77;,d74  7,,iii7 ,compliance
 ) prompt paym5t requirem5ts1 includ+   
compliance ) section #aheg7;f74  7,,iv7 
,compliance ) re/rictions reg>d+ improp]

 retroactive d5ials & d[ngrades1 includ+
 compliance ) section #aheb7;g77#f7 &   
section #aheg7;e77#f74  7,v7 ,compliance
 ) m>ket+1 enrollm5t1 & b5efici>y       
communication requirem5ts1 includ+      
subp>t ,v ( "p #dbb ( title #db1 ,code (
 ,f$]al ,regulations1 or any successor  
to su* regulations4  7,,vi7 ,compliance 
) o!r requirem5ts "u ?is "p1 includ+    
section #aheb7;g77#a77;,e7 & su* o!r    
requirem5ts z specifi$ by ! ,secret>y4  
7ii7 ,updates ,! ,secret>y may1 ?r\gh   
notice & comm5t rulemak+1 revise !      
compliance categories describ$ 9 clause 
7i71 includ+ by specify+ additional     
categories1 remov+ categories1 & o!rwise
 updat+ ! requirem5ts t are includ$ 9   
any ( su* compliance categories4  7#d7  
,scor+ me?odology ,"u ! ,,mao           
,compliance ,program1 ! ,secret>y %all1 
?r\gh notice & comm5t rulemak+1 e/abli% 
a me?odology to assign a total          
compliance score 7us+ a scor+ scale ( #j
 to #ajj7 to ea* ,m$ic>e ,advantage     
organization = ! p]=mance p]iod )       

respect to a plan ye>4 ,su* total       
compliance score %all be bas$ on !      
assessm5t "u p>agraph 7#c7 ( plan-level 
compliance ) respect to ea* compliance  
category describ$ 9 subp>agraph 7,b7 (  
su* p>agraph1 ) ea* su* category receiv+
 equal weight 7&1 9 ! case ( a ,m$ic>e  
,advantage organization (f]+ m ?an "o   
plan dur+ ! p]=mance p]iod1 ) ea* su*   
assessm5t weight$ by ! numb] (          
individuals enroll$ "u su* plan dur+ su*
 p]iod74  7#e7 ,compliance ti]s ,= ea*  
plan ye> beg9n+ on or aft] ,janu>y #a1  
#bjbh1 ! ,secret>y %all1 bas$ on ! total
 compliance score assign$ pursuant to   
p>agraph 7#d7 to a ,m$ic>e ,advantage   
organization = ! p]=mance p]iod )       
respect to su* ye>1 assign su* ,m$ic>e  
,advantage organization to "o ( ! foll[+
 compliance ti]s1 z foll[s3 7,a7        
,compliance ti] "o1 consi/+ ( ,m$ic>e   
,advantage organizations receiv+ a total
 score = ! p]=mance p]iod ( at lea/ #ij4
  7,b7 ,compliance ti] two1 consi/+ (   
,m$ic>e ,advantage organizations receiv+

 a total score = ! p]=mance p]iod ( at  
lea/ #ge b n m ?an #hi4  7,c7           
,compliance ti] ?ree1 consi/+ ( ,m$ic>e 
,advantage organizations receiv+ a total
 score = ! p]=mance p]iod ( at lea/ #fj 
b n m ?an #gd4  7,d7 ,compliance ti]    
f\r1 consi/+ ( ,m$ic>e ,advantage       
organizations receiv+ a total score = ! 
p]=mance p]iod ( less ?an #fj4  7#f7    
,review ,! ,secret>y %all e/abli% a     
process "u :i* a ,m$ic>e ,advantage     
organization may seek a review ( ! total
 compliance score assign$ to !          
organization pursuant to p>agraph 7#d7 =
 a p]=mance p]iod4  7#g7 ,public        
disclosures  7,a7 ,9 g5]al ,= ea* plan  
ye> beg9n+ on or aft] ,janu>y #a1 #bjbh1
 ! ,secret>y %all make available on a   
public website ( ! ,c5t]s = ,m$ic>e     
,m$icaid ,s]vices & 9 an easily         
und]/&able =mat1 in=mation reg>d+ !     
assessm5ts "u ! ,,mao ,compliance       
,program ( compliance dur+ ! p]=mance   
p]iod ) respect to ! plan ye> by ,m$ic>e
 ,advantage organizations1 on ! plan    

level1 ) requirem5ts applicable to ea*  
compliance category specifi$ 9 p>agraph 
7#c77;,b74 ,su* in=mation %all include !
 total compliance score receiv$ by ea*  
,m$ic>e ,advantage organization pursuant
 to p>agraph 7#d7 = ! p]=mance p]iod4   
7,b7 ,opportunity to review & submit    
corrections ,! ,secret>y %all provide = 
an opportunity = a ,m$ic>e ,advantage   
organization to review & submit         
corrections = ! in=mation to be made    
available "u subp>agraph 7,a7 ) respect 
to su* organization prior to su*        
in=mation be+ made public4  4  7b7      
,exp&+ ! ,,ma /> rat+s program ,to      
include an ,,ma program compliance &    
cov]age protection doma9  7#a7  ,data   
collection  ,section #aheb7;e77#c7 ( !  
,social ,security ,act                  
7#aciew-#bb7;e77#c77 is am5d$-- 7,a7 9  
subp>agraph 7,a77i71 9 ! fir/ s5t5ce by 
ins]t+ 1 includ+1 = plan ye>s beg9n+ on 
or aft] ,janu>y #a1 #bjbh1 ) respect to 
measures "u ! ,,ma ,program ,compliance 
& ,cov]age ,protection ,doma9 describ$ 9

 section #ahec7o77#h7 aft] o!r indices (
 quality2 &  7,b7 9 subp>agraph 7,b77i71
 by ins]t+ 1 & o!r ?an ! types ( data   
au?oriz$ "u subp>agraph 7,c7 ( section  
#ahec7o77#h7 = purposes ( ! ,,ma        
,program ,compliance & ,cov]age         
,protection ,doma9 describ$ 9 su*       
section aft] z ( ,novemb] #a1 #bjjc4    
7#b7  ,addition ( ,,ma program          
compliance & cov]age protection doma9 to
 ,,ma /> rat+s sy/em  ,section #ahec7o7 
( ! ,social ,security ,act              
7#aciew-#bc7o77 is am5d$ by add+ at !   
end ! foll[+ new p>agraph3  7#h7  ,,ma  
program compliance & cov]age protection 
doma9  7,a7  ,9 g5]al  ,= plan ye>s     
beg9n+ on or aft] ,janu>y #a1 #bjbh1 9  
addition to any o!r doma9 "u ! #e-/>    
rat+ sy/em "u p>agraph 7#d77;,a7 us$ =  
det]m9+ /> rat+s ( ,m$ic>e ,advantage   
plans1 ! ,secret>y %all include "u su*  
sy/em an ,,ma ,program ,compliance &    
,cov]age ,protection ,doma94  7,b7      
,measures  ,su* doma9 %all include      
measures to assess compliance ( ea*     

,m$ic>e ,advantage plan ) ea* ( !       
compliance categories specifi$ 9 section
 #ahec7p77#c77;,b74  7,c7  ,data  ,=    
purposes ( det]m9+ /> rat+s ) respect to
 measures "u ! ,,ma ,program ,compliance
 & ,cov]age ,protection ,doma91 9       
addition to s\rces ( data o!rwise       
collect$ "u section #aheb7;e77#c71 !    
,secret>y may use data collect$ pursuant
 to audits1 compla9t track+ sy/ems1     
appeals data1 det]m9ations made by      
indep5d5t review entities1 & su* o!r    
s\rces z specifi$ by ! ,secret>y4  7,d7 
,application ( weight+  ,9 apply+       
section #dbb4aff7;e7 ( title #db1 ,code 
( ,f$]al ,regulations1 or a successor   
regulation1 ) respect to ! ,,ma ,program
 ,compliance & ,cov]age ,protection     
,doma91 ! ,secret>y %all assign a weight
 to measures includ$ "u su* doma9 t is  
great] ?an ! weight assign$ to measures 
includ$ "u any o!r doma94  4  #d4       
,gu>drails on retrospective clawbacks   
7a7 ,application ( prompt paym5t        
requirem5ts to all claims = :i*         

au?orization 0 provid$ ,section         
#aheg7;f7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #aciew-#bg7;f77 is       
am5d$-- 7#a7 9 p>agraph 7#a7--  7,a7 9 !
 head]1 by ins]t+ = items & s]vices     
furni%$ by out-(-network provid]s (     
s]vices & suppli]s aft] requirem5t2 &   
7,b7 by /rik+ ,a contract & ins]t+      
,subject to p>agraph 7#b71 a contract2  
7#b7 9 p>agraph 7#b71 by /rik+ 9        
compliance ) p>agraph 7#a7 & ins]t+ 9   
compliance ) p>agraphs 7#a7 & 7#b72     
7#c7 by r$esignat+ p>agraphs 7#b7 & 7#c7
 z p>agraphs 7#c7 & 7#d71 respectively2 
&  7#d7 by ins]t+ aft] p>agraph 7#a7 !  
foll[+ new p>agraph3  7#b7 ,requirem5t =
 items & s]vices = :i* au?orization 0   
provid$  7,a7 ,9 g5]al ,= contract ye>s 
beg9n+ on or aft] ,janu>y #a1 #bjbh1 a  
contract "u ?is "p %all require a       
,m$ic>e ,advantage organization to      
provide prompt paym5t 7consi/5t ) !     
provisions ( sections #ahaf7;c77#b7 &   
#ahdb7;c77#b77 ( qualify+ claims        
submitt$ = au?oriz$ items & s]vices 7z  

def9$ 9 subp>agraph 7,b77 furni%$ to    
enrollees "u ! plan1 except t 9 apply+ !
 provisions ( su* sections--  7i7       
ref]5ces to n less ?an #ie p]c5t ( all  
claims submitt$ %all be treat$ z        
ref]5ces to #ajj p]c5t ( all claims     
submitt$2 &  7ii7 e qualify+ claim 7z   
describ$ 9 subp>agraph 7,c77 submitt$ = 
an au?oriz$ item or s]vice %all be deem$
 to be a clean claim ref]r$ to 9 su*    
sections4  7,b7 ,au?oriz$ item or s]vice
 def9$ ,= purposes ( ?is p>agraph1 ! t]m
 au?oriz$ item or s]vice means an item  
or s]vice-- 7i7 t is furni%$ by a       
provid] ( s]vice or suppli] to an       
individual enroll$ 9 a ,m$ic>e          
,advantage plan (f]$ by a ,m$ic>e       
,advantage organization2 &  7ii7 = :i*  
approval 0 provid$ by ! ,m$ic>e         
,advantage organization ?r\gh a specifi$
 au?orization 7z def9$ 9 section        
#aheb7;g77#a77;,c77iii774  7,c7         
,qualify+ claim describ$ ,= purposes (  
?is p>agraph1 a claim = an au?oriz$ item
 or s]vice is a qualify+ claim if x     

includes in=mation suffici5t to e/abli% 
t approval = su* item or s]vice 0       
provid$ z describ$ 9 subp>agraph        
7,b77ii74  4  7b7 ,effect ( specifi$    
au?orizations ,section #aheg7;e7 ( !    
,social ,security ,act 7#db ,u4,s4,c4   
#acie;e-#bg7;e77 is am5d$ by add+ at !  
end ! foll[+ new p>agraph3  7#f7 ,effect
 ( specifi$ au?orizations ,beg9n+ ) plan
 ye>s beg9n+ on or aft] ,janu>y #a1     
#bjbh1 a contract "u ?is section ) an   
,,ma organization %all require t1 9 !   
case t ! ,,ma organization approves !   
furni%+ to an individual enroll$ "u an  
,,ma plan (f]$ by su* ,,ma organization 
( an item or s]vice ?r\gh a specifi$    
au?orization 7z def9$ 9 section         
#aheb7;g77#a77;,c77iii77 made dur+ !    
receipt by ! individual ( su* item or   
s]vice--  7,a7 ! ,,ma organization may  
n1 aft] su* approval1 d5y cov]age ( su* 
item or s]vice on ! basis ( lack (      
m$ical necessity & may n reop5 su* a    
decision = any reason except = good     
cause 7z describ$ 9 sections #dje4ihf & 

#dbb4faf ( title #db1 ,code ( ,f$]al    
,regulations 7or any successor          
regulation77 or if !re is reliable      
evid5ce ( fraud or simil> fault 7z su*  
t]ms are def9$ 9 section #dje4ijb ( su* 
title 7or any successor regulation71 z  
det]m9$ 9 accordance ) section #dbb4faf 
( su* title 7or any successor           
regulation772 &  7,b7 ! ,,ma            
organization may n1 aft] su* approval1  
*ange ! code assign$ ) respect to !     
claim = su* item or s]vice su* t ! am\nt
 ( paym5t = su* claim w\ld be r$uc$1    
except = good cause 7z describ$ 9       
subp>agraph 7,a77 or if !re is reliable 
evid5ce ( fraud or simil> fault 7z s    
describ$74  4  7c7 ,limitation on use ( 
?ird-,p>ty po/-,claim review entities   
,section #aheb7;g7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #aciew-#b7;g77 is  
am5d$ by add+ at ! end ! foll[+ new     
p>agraph3  7#f7  ,limitations on use (  
?ird-p>ty reviews  7,a7  ,9 g5]al  ,=   
contract ye>s beg9n+ on or aft] ,janu>y 
#a1 #bjbh1 proc$ures e/abli%$ by a      

,m$ic>e ,advantage organization = mak+  
det]m9ations "u p>agraph 7#a71          
reconsid]ations "u p>agraph 7#b71 or    
exp$it$ det]m9ations or reconsid]ations 
"u p>agraph 7#c71 & proc$ures e/abli%$ =
 provid+ = any po/-paym5t review process
 %all--  7i7 prohibit any ?ird-p>ty     
entity f conduct+ a m$ical necessity    
review = cov]age1 paym5t1 or po/-paym5t 
review = su* ,m$ic>e ,advantage         
organization unless--  7,i7 su* review  
is n ) respect to an au?oriz$ item or   
s]vice 7z def9$ 9 section               
#aheg7;f77#b77;,b772 &  7,,ii7 su*      
entity is 9 compliance ) ! requirem5ts  
describ$ 9 subp>agraph 7,b72  7ii7      
prohibit ! use ( any ?ird-p>ty review t 
is conduct$ us+ a r\t9e1 automat$       
process = d5ials 9 any su* review1 claim
 d5ials1 or patt]n-bas$ practices (     
*ang+ a code assign$ ) respect to a     
claim = an item or s]vice furni%$ to    
individuals enroll$ "u an ,,ma plan (f]$
 by ! ,m$ic>e ,advantage organization to
 a code t w\ld result 9 a r$uction 9 !  

am\nt ( paym5t = su* claim aft] ! item  
or s]vice has be5 furni%$ to !          
individual2 &  7iii7 prohibit any       
comp5sation arrangem5t ) any ?ird-p>ty  
entity t provides = paym5t or o!r       
comp5sation to su* entity bas$ on !     
numb]1 p]c5tage1 or am\nt ( specifi$    
au?orization reque/s 7z def9$ 9 section 
#aheb7;g77#a77;,c77iii77 t ! entity     
approves1 d5ies1 or o!rwise recomm5ds = 
approval or d5ial4  7,b7  ,requirem5ts  
,= purposes ( subp>agraph 7,a71 !       
requirem5ts specifi$ 9 ?is subp>agraph1 
) respect to a ?ird-p>ty entity & a     
review describ$ 9 su* subp>agraph1 are  
ea* ( ! foll[+3  7i7 ,! entity conducts 
su* review 9 accordance ) audit         
protocols & appeal rights1 z applicable1
 t are specifi$ by ! ,secret>y4  7ii7 ,!
 entity complies ) audit & public       
transp>5cy report+ requirem5ts specifi$ 
by ! ,secret>y4  4  #e4 ,cov]age &      
m$ical necessity crit]ia us$ by ,m$ic>e 
,advantage organizations  7a7           
,codification "u ! ,m$ic>e ,advantage   

program ( two-,midnight b5*m>k &        
presumption rules  ,section             
#aheb7;g77#a7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciew-#bb7;g77#a771 z  
am5d$ by section #b1 is fur!r am5d$ by  
add+ at ! end ! foll[+ new subp>agraph3 
7,e7  ,application ( two-midnight rules 
,! proc$ures "u subp>agraph 7,a7 %all   
provide t1 = mak+ det]m9ations describ$ 
9 su* subp>agraph ) respect to hospital 
& critical access hospital admissions-- 
7i7 9 det]m9+ :e!r an individual is an  
inpati5t ( a hospital or critical access
 hospital1 ! ,m$ic>e ,advantage         
organization %all cont9ue to apply !    
provisions ( section #dab4c7;d7 ( title 
#db1 ,code ( ,f$]al ,regulations1 or any
 successor regulation1 9 ! same mann] & 
to ! same ext5t z su* provisions apply )
 respect to paym5t "u "p ,a2 &  7ii7    
beg9n+ on ,janu>y #a1 #bjbh1 9 conduct+ 
m$ical review activities1 ) respect to  
su* admissions1 ! ,m$ic>e ,advantage    
organization %all apply ! #b-midnight   
presumption f9aliz$ 9 ! rule publi%$ by 

! ,secret>y 9 ! ,f$]al ,regi/] on ,augu/
 #ai1 #bjac 7#gh ,f$4 ,reg4 #ejieb71 or 
any successor regulation1 9 ! same mann]
 & to ! same ext5t z su* provisions     
apply ) respect to paym5t "u "p ,a4  4  
7b7  ,requir+ consi/5t m$ical necessity 
crit]ia betwe5 ,m$ic>e ,advantage &     
orig9al fee-=-,s]vice  7#a7  ,9 g5]al   
,section #aheb7;g7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #aciew-#bb7;g771 z 
am5d$ by section #d7;c71 is fur!r       
am5d$--  7,a7 9 p>agraph 7#b77;,b71 by  
/rik+ ,a reconsid]ation relat+ & ins]t+ 
,9 accordance ) p>agraph 7#g77;,c71 a   
reconsid]ation relat+2 &  7,b7 by add+  
at ! end ! foll[+ new p>agraph3  7#g7   
,m$ical necessity det]m9$ bas$ on ,,ffs 
reasonable & necess>y crit]ia  7,a7 ,9  
g5]al ,= purposes ( a det]m9ation or    
reconsid]ation "u ?is subsection made on
 or aft] ,janu>y #a1 #bjbh1 or a review 
made on or aft] su* date by an          
indep5d5t1 outside entity "u p>agraph   
7#d71 ) respect to cov]age = an item or 
s]vice furni%$ to an individual enroll$ 

9 an ,,ma plan (f]$ by a ,m$ic>e        
,advantage organization1 ! ,m$ic>e      
,advantage organization or indep5d5t1   
outside entity1 respectively1 %all n    
apply crit]ia = det]m9+ ! m$ical        
necessity ( su* item or s]vice t is m   
re/rictive ?an ! /&>ds & crit]ia appli$ 
pursuant to section #ahfb7;a77#a7 =     
det]m9+ "u p>ts ,a & ,b :e!r ! item or  
s]vice is reasonable & necess>y4  7,b7  
,c]ta9 cov]age crit]ia  ,= purposes ( a 
det]m9ation or reconsid]ation "u ?is    
subsection made on or aft] ,janu>y #a1  
#bjbh1 or a review made on or aft] su*  
date by an indep5d5t1 outside entity "u 
p>agraph 7#d71 ) respect to cov]age (   
inpati5t hospital s]vices furni%$ by a  
rehabilitation facility 7z ref]r$ to 9  
section #ahff7;j77#a77;,a77 or long-t]m 
c>e hospital to an individual enroll$ 9 
an ,,ma plan (f]$ by a ,m$ic>e          
,advantage organization1 ! ,m$ic>e      
,advantage organization or indep5d5t1   
outside entity1 respectively1 %all n    
apply cov]age crit]ia t is m re/rictive 

?an ! /&>ds & crit]ia appli$ "u p>ts ,a 
& ,b1 includ+ "u--  7i7 subsections     
7a77#c71 7a77#d71 & 7a77#e7 ( section   
#dab4fbb ( title #db1 ,code ( ,f$]al    
,regulations 7or any successor to su*   
regulation71 ) respect to su* a         
rehabilitation facility2 &  7ii7        
p>agraphs 7#a71 7#c71 & 7#d7 ( section  
#ahfa7;ccc7 & clauses 7iii7 & 7iv7 (    
section #ahhf7m77#f77;,a71 ) respect to 
a long-t]m c>e hospital4  7,c7          
,p]sonnel  ,= purposes ( subp>agraph    
7,a71 a det]m9ation1 reconsid]ation1 or 
review reg>d+ ! m$ical necessity ( an   
item or s]vice %all be made only by a   
physician or o!r heal? c>e pr(essional )
 appropriate exp]tise1 includ+          
education1 ) respect to su* item or     
s]vice & ! relat$ /&>ds & crit]ia appli$
 pursuant to section #ahfb7;a77#a74 ,=  
purposes ( subp>agraph 7,b71 a          
det]m9ation1 reconsid]ation1 or review  
reg>d+ cov]age ( inpati5t hospital      
s]vices furni%$ by a facility or        
hospital describ$ 9 su* subp>agraph %all

 be made only by a physician or o!r     
heal? c>e pr(essional ) appropriate     
exp]tise1 includ+ education1 ) respect  
to su* s]vices & ! relat$ /&>ds &       
crit]ia appli$ pursuant to su*          
subp>agraph4  4  7#b7  ,en=cem5t        
,section #aheg7;g77#a7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#aciew-#bg7;g77#a77 is am5d$--  7,a7 by 
r$esignat+ subp>agraph 7,k7 z           
subp>agraph 7,l72  7,b7 by /rik+ or at !
 end ( subp>agraph 7,j72  7,c7 by ins]t+
 aft] subp>agraph 7,j7 ! foll[+         
subp>agraph3  7,k7 fails to comply )    
section #aheb7;g77#g72 or  2  7,d7 9    
subp>agraph 7,l71 z r$esignat$ by       
subp>agraph 7,a71 by /rik+ subp>agraphs 
7,a7 ?r\gh 7,j7 & ins]t+ subp>agraphs   
7,a7 ?r\gh 7,k72 &  7,e7 9 ! matt]      
foll[+ su* subp>agraph 7,l71 by /rik+   
subp>agraphs 7,a7 ?r\gh 7,k7 & ins]t+   
subp>agraphs 7,a7 ?r\gh 7,l74  7c7      
,requir+ transp>5cy 9 cov]age crit]ia   
,section #aheb7;a77#b7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           

#aciew-#bb7;a77#b77 is am5d$ by add+ at 
! end ! foll[+ new subp>agraph3  7,d7   
,transp>5cy 9 cov]age crit]ia  7i7      
,requirem5t ,= plan ye>s beg9n+ on or   
aft] ,janu>y #a1 #bjbh1 9 ord] to meet !
 requirem5t "u p>agraph 7#a77;,a71 9 !  
case ( an item or s]vice = :i* !re is no
 national cov]age det]m9ation1          
applicable local cov]age det]m9ation1 or
 applicable guidance = cov]age provid$  
by ! ,secret>y1 a ,m$ic>e ,advantage    
organization (f]+ an ,,ma plan %all--   
7,i7 make a cov]age det]m9ation )       
respect to su* item or s]vice 9         
accordance ) publicly available         
evid5ce-bas$ cov]age crit]ia t is       
publi%$ on a public website ( ! ,m$ic>e 
,advantage organization2 &  7,,ii7      
submit to ! ,secret>y in=mation1 )      
respect to e m$ical necessity           
det]m9ation made 9 ! abs5ce ( su*       
national cov]age det]m9ation1 applicable
 local cov]age det]m9ation1 or          
applicable guidance = cov]age1 specify+ 
! cov]age crit]ia appli$ "u ! ,,ma plan4

  7ii7 ,use ( in=mation ,! ,secret>y    
%all use ! in=mation submitt$ "u clause 
7i77,,ii7 to prioritize cov]age         
det]m9ations4  4  #f4 ,elim9at+         
ineffici5cies 9 adm9i/rative process+ by
 ,m$ic>e ,advantage organizations  7a7  
,apply+ fee-=-,s]vice prompt paym5t     
requirem5ts to ,,ma 9-,network s]vices z
 well z out-(-,network s]vices ,section 
#aheg7;f77#a7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciew-#bg7;f77#a771 z  
am5d$ by section #d7;a71 is fur!r       
am5d$--  7#a7 9 ! p>agraph head+1 by    
ins]t+ 9-network & be=e out-(-network2 &
  7#b7 by /rik+ if ! s]vices or supplies
 & all t foll[s ?r\gh ! p]iod at ! end &
 ins]t+ reg>dless ( :e!r ! s]vices or   
supplies are furni%$ "u a contract      
betwe5 ! organization & ! provid] (     
s]vices or suppli]4 ,a claim t is       
det]m9$ to be a clean claim pursuant to 
! previ\s s5t5ce or p>agraph 7#b7 may n 
subsequ5tly be det]m9$ to n be a clean  
claim except "u su* circum/ances & 9    
accordance ) su* crit]ia z specifi$ by !

 ,secret>y pursuant to notice & comm5t  
rulemak+44  7b7 ,automat$ review &      
paym5t = c]ta9 claims ,section #aheg7;f7
 ( ! ,social ,security ,act 7#db        
,u4,s4,c4 #aciew-#bg7;f771 z am5d$ by   
section #d7;a71 is fur!r am5d$-- 7#a7 by
 r$esignat+ p>agraphs 7#c7 & 7#d7 z     
p>agraphs 7#d7 & 7#e71 respectively2 &  
7#b7 by ins]t+ aft] p>agraph 7#b7 !     
foll[+ new p>agraph3  7#c7 ,automat$    
review & paym5t = c]ta9 claims  7,a7 ,9 
g5]al ,= plan ye>s beg9n+ on or aft]    
,janu>y #a1 #bjbh1 a ,m$ic>e ,advantage 
organization %all h 9 place automat$    
paym5t processes1 9 accordance ) /&>ds  
specifi$ by ! ,secret>y1 = claims       
describ$ 9 subp>agraph 7,b7 ) respect to
 :i* ! provisions ( p>agraph 7#a7 or    
7#b7 apply4 ,su* processes %all provide 
t su* claims %all be automatically      
process$ & paid & %all n be subject to  
manual claim review1 except 9 cases =   
:i* !re is reasonable evid5ce ( fraud4  
7,b7 ,specifi$ claims ,= purposes (     
subp>agraph 7,a71 a claim describ$ 9 ?is

 subp>agraph is a claim t-- 7i7 is = an 
au?oriz$ item or s]vice 7z def9$ 9      
p>agraph 7#b77;,b772 or  7ii7 is = an   
item or s]vice id5tifi$ on ! mo/ rec5t  
li/ publi%$ pursuant to section         
#aheb7;g77#a77;,d77iii74  4  #g4        
,modification to network adequacy /&>ds 
= c]ta9 po/-acute c>e provid]s ,section 
#aheb7;d77#a7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciew-#bb7;d77#a77 is  
am5d$--  7#a7 9 subp>agraph 7,d71 by    
/rik+ & at ! end2  7#b7 9 subp>agraph   
7,e71 by /rik+ ! p]iod at ! end & ins]t+
 2 &2 &  7#c7 by add+ at ! end ! foll[+ 
new subp>agraph3  7,f7 = plan ye>s      
beg9n+ on or aft] ,janu>y #a1 #bjbh1 !  
organization provides adequate access to
 long-t]m c>e hospitals & inpati5t      
rehabilitation facilities1 z det]m9$ 9  
accordance ) network adequacy /&>ds     
specifi$ by ! ,secret>y4  4