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H.R.4577
Departments of Labor, Health and Human Services, and Education, and
Related Agencies Appropriations Act, 2001 (Public Print)
SEC. 2212. INFORMATION ABOUT PROVIDERS.
(a) STUDY- The Secretary of Health and Human Services shall enter into
a contract with the Institute of Medicine for the conduct of a study, and the
submission to the Secretary of a report, that includes--
(1) an analysis of information concerning health care professionals
that is currently available to patients , consumers, States, and
professional societies, nationally and on a State-by-State basis, including
patient preferences with respect to information about such professionals and
their competencies;
(2) an evaluation of the legal and other barriers to the sharing of
information concerning health care professionals; and
(3) recommendations for the disclosure of information on health care
professionals, including the competencies and professional qualifications of
such practitioners, to better facilitate patient choice, quality
improvement, and market competition.
(b) REPORT- Not later than 18 months after the date of enactment of
this Act, the Secretary of Health and Human Services shall forward to the
appropriate committees of Congress a copy of the report and study conducted
under subsection (a).
Subtitle C--Right to Hold Health Plans
Accountable
SEC. 2221. AMENDMENTS TO EMPLOYEE RETIREMENT INCOME SECURITY ACT OF
1974.
(a) IN GENERAL- Part 5 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974 is amended by inserting after section
503 (29 U.S.C. 1133) the following:
`SEC. 503A. CLAIMS AND INTERNAL APPEALS PROCEDURES FOR GROUP HEALTH
PLANS.
`(a) INITIAL CLAIM FOR BENEFITS UNDER GROUP HEALTH PLANS-
`(A) IN GENERAL- A group health plan, or health insurance issuer
offering health insurance coverage in connection with a group health plan,
shall ensure that procedures are in place for--
`(i) making a determination on an initial claim for benefits by
a participant or beneficiary (or authorized representative) regarding
payment or coverage for items or services under the terms and conditions
of the plan or coverage involved, including any cost-sharing amount that
the participant or beneficiary is required to pay with respect to such
claim for benefits; and
`(ii) notifying a participant or beneficiary (or authorized
representative) and the treating health care professional involved
regarding a determination on an initial claim for benefits made under
the terms and conditions of the plan or coverage, including any
cost-sharing amounts that the participant or beneficiary may be required
to make with respect to such claim for benefits, and of the right of the
participant or beneficiary to an internal appeal under subsection
(b).
`(B) ACCESS TO INFORMATION- With respect to an initial claim for
benefits, the participant or beneficiary (or authorized representative)
and the treating health care professional (if any) shall provide the plan
or issuer with access to information necessary to make a determination
relating to the claim, not later than 5 business days after the date on
which the claim is filed or to meet the applicable timelines under clauses
(ii) and (iii) of paragraph (2)(A).
`(C) ORAL REQUESTS- In the case of a claim for benefits involving
an expedited or concurrent determination, a participant or beneficiary (or
authorized representative) may make an initial claim for benefits orally,
but a group health plan, or health insurance issuer offering health
insurance coverage in connection with a group health plan, may require
that the participant or beneficiary (or authorized representative) provide
written confirmation of such request in a timely manner.
`(2) TIMELINE FOR MAKING DETERMINATIONS-
`(A) PRIOR AUTHORIZATION DETERMINATION-
`(i) IN GENERAL- A group health plan, or health insurance issuer
offering health insurance coverage in connection with a group health
plan, shall maintain procedures to ensure that a prior authorization
determination on a claim for benefits is made within 14 business days
from the date on which the plan or issuer receives information that is
reasonably necessary to enable the plan or issuer to make a
determination on the request for prior authorization, but in no case
shall such determination be made later than 28 business days after the
receipt of the claim for benefits.
`(ii) EXPEDITED DETERMINATION- Notwithstanding clause (i), a
group health plan, or health insurance issuer offering health insurance
coverage in connection with a group health plan, shall maintain
procedures for expediting a prior authorization determination on a claim
for benefits described in such clause when a request for such an
expedited determination is made by a participant or beneficiary (or
authorized representative) at any time during the process for making a
determination and the treating health care professional substantiates,
with the request, that a determination under the procedures described in
clause (i) would seriously jeopardize the life or health of the
participant or beneficiary. Such determination shall be made within 72
hours after a request is received by the plan or issuer under this
clause.
`(iii) CONCURRENT DETERMINATIONS- A group health plan, or health
insurance issuer offering health insurance coverage in connection with a
group health plan, shall maintain procedures to ensure that a concurrent
determination on a claim for benefits that results in a discontinuation
of inpatient care is made within 24 hours after the receipt of the claim
for benefits.
`(B) RETROSPECTIVE DETERMINATION- A group health plan, or health
insurance issuer offering health insurance coverage in connection with a
group health plan, shall maintain procedures to ensure that a
retrospective determination on a claim for benefits is made within 30
business days of the date on which the plan or issuer receives information
that is reasonably necessary to enable the plan or issuer to make a
determination on the claim, but in no case shall such determination be
made later than 60 business days after the receipt of the claim for
benefits.
`(3) NOTICE OF A DENIAL OF A CLAIM FOR BENEFITS- Written notice of a
denial made under an initial claim for benefits shall be issued to the
participant or beneficiary (or authorized representative) and the treating
health care professional not later than 2 business days after the
determination (or within the 72-hour or 24-hour period referred to in
clauses (ii) and (iii) of paragraph (2)(A) if applicable).
`(4) REQUIREMENTS OF NOTICE OF DETERMINATIONS- The written notice of
a denial of a claim for benefits determination under paragraph (3) shall
include--
`(A) the reasons for the determination (including a summary of the
clinical or scientific-evidence based rationale used in making the
determination and instruction on obtaining a more complete description
written in a manner calculated to be understood by the average
participant);
`(B) the procedures for obtaining additional information
concerning the determination; and
`(C) notification of the right to appeal the determination and
instructions on how to initiate an appeal in accordance with subsection
(b).
`(b) INTERNAL APPEAL OF A DENIAL OF A CLAIM FOR BENEFITS-
`(1) RIGHT TO INTERNAL APPEAL-
`(A) IN GENERAL- A participant or beneficiary (or authorized
representative) may appeal any denial of a claim for benefits under
subsection (a) under the procedures described in this
subsection.
`(B) TIME FOR APPEAL- A group health plan, or health insurance
issuer offering health insurance coverage in connection with a group
health plan, shall ensure that a participant or beneficiary (or authorized
representative) has a period of not less than 60 days beginning on the
date of a denial of a claim for benefits under subsection (a) in which to
appeal such denial under this subsection.
`(C) FAILURE TO ACT- The failure of a plan or issuer to issue a
determination on a claim for benefits under subsection (a) within the
applicable timeline established for such a determination under such
subsection shall be treated as a denial of a claim for benefits for
purposes of proceeding to internal review under this
subsection.
`(D) PLAN WAIVER OF INTERNAL REVIEW- A group health plan, or
health insurance issuer offering health insurance coverage in connection
with a group health plan, may waive the internal review process under this
subsection and permit a participant or beneficiary (or authorized
representative) to proceed directly to external review under section
503B.
`(2) TIMELINES FOR MAKING DETERMINATIONS-
`(A) ORAL REQUESTS- In the case of an appeal of a denial of a
claim for benefits under this subsection that involves an expedited or
concurrent determination, a participant or beneficiary (or authorized
representative) may request such appeal orally, but a group health plan,
or health insurance issuer offering health insurance coverage in
connection with a group health plan, may require that the participant or
beneficiary (or authorized representative) provide written confirmation of
such request in a timely manner.
`(B) ACCESS TO INFORMATION- With respect to an appeal of a denial
of a claim for benefits, the participant or beneficiary (or authorized
representative) and the treating health care professional (if any) shall
provide the plan or issuer with access to information necessary to make a
determination relating to the appeal, not later than 5 business days after
the date on which the request for the appeal is filed or to meet the
applicable timelines under clauses (ii) and (iii) of subparagraph
(C).
`(C) PRIOR AUTHORIZATION DETERMINATIONS-
`(i) IN GENERAL- A group health plan, or health insurance issuer
offering health insurance coverage in connection with a group health
plan, shall maintain procedures to ensure that a determination on an
appeal of a denial of a claim for benefits under this subsection is made
within 14 business days after the date on which the plan or issuer
receives information that is reasonably necessary to enable the plan or
issuer to make a determination on the appeal, but in no case shall such
determination be made later than 28 business days after the receipt of
the request for the appeal.
`(ii) EXPEDITED DETERMINATION- Notwithstanding clause (i), a
group health plan, or health insurance issuer offering health insurance
coverage in connection with a group health plan, shall maintain
procedures for expediting a prior authorization determination on an
appeal of a denial of a claim for benefits described in clause (i), when
a request for such an expedited determination is made by a participant
or beneficiary (or authorized representative) at any time during the
process for making a determination and the treating health care
professional substantiates, with the request, that a determination under
the procedures described in clause (i) would seriously jeopardize the
life or health of the participant or beneficiary. Such determination
shall be made not later than 72 hours after the request for such appeal
is received by the plan or issuer under this clause.
`(iii) CONCURRENT DETERMINATIONS- A group health plan, or health
insurance issuer offering health insurance coverage in connection with a
group health plan, shall maintain procedures to ensure that a concurrent
determination on an appeal of a denial of a claim for benefits that
results in a discontinuation of inpatient care is made within 24 hours
after the receipt of the request for appeal.
`(B) RETROSPECTIVE DETERMINATION- A group health plan, or health
insurance issuer offering health insurance coverage in connection with a
group health plan, shall maintain procedures to ensure that a
retrospective determination on an appeal of a claim for benefits is made
within 30 business days of the date on which the plan or issuer receives
necessary information that is reasonably required by the plan or issuer to
make a determination on the appeal, but in no case shall such
determination be made later than 60 business days after the receipt of the
request for the appeal.
`(A) IN GENERAL- A review of a denial of a claim for benefits
under this subsection shall be conducted by an individual with appropriate
expertise who was not directly involved in the initial
determination.
`(B) REVIEW OF MEDICAL DECISIONS BY PHYSICIANS- A review of an
appeal of a denial of a claim for benefits that is based on a lack of
medical necessity and appropriateness, or based on an experimental or
investigational treatment, or requires an evaluation of medical facts,
shall be made by a physician with appropriate expertise, including
age-appropriate expertise, who was not involved in the initial
determination.
`(4) NOTICE OF DETERMINATION-
`(A) IN GENERAL- Written notice of a determination made under an
internal appeal of a denial of a claim for benefits shall be issued to the
participant or beneficiary (or authorized representative) and the treating
health care professional not later than 2 business days after the
completion of the review (or within the 72-hour or 24-hour period referred
to in paragraph (2) if applicable).
`(B) FINAL DETERMINATION- The decision by a plan or issuer under
this subsection shall be treated as the final determination of the plan or
issuer on a denial of a claim for benefits. The failure of a plan or
issuer to issue a determination on an appeal of a denial of a claim for
benefits under this subsection within the applicable timeline established
for such a determination shall be treated as a final determination on an
appeal of a denial of a claim for benefits for purposes of proceeding to
external review under section 503B.
`(C) REQUIREMENTS OF NOTICE- With respect to a determination made
under this subsection, the notice described in subparagraph (A) shall
include--
`(i) the reasons for the determination (including a summary of
the clinical or scientific-evidence based rationale used in making the
determination and instruction on obtaining a more complete description
written in a manner calculated to be understood by the average
participant);
`(ii) the procedures for obtaining additional information
concerning the determination; and
`(iii) notification of the right to an independent external
review under section 503B and instructions on how to initiate such a
review.
`(c) DEFINITIONS- The definitions contained in section 503B(i) shall
apply for purposes of this section.
`SEC. 503B. INDEPENDENT EXTERNAL APPEALS PROCEDURES FOR GROUP HEALTH
PLANS.
`(a) RIGHT TO EXTERNAL APPEAL- A group health plan, and a health
insurance issuer offering health insurance coverage in connection with a group
health plan, shall provide in accordance with this section participants and
beneficiaries (or authorized representatives) with access to an independent
external review for any denial of a claim for benefits.
`(b) INITIATION OF THE INDEPENDENT EXTERNAL REVIEW PROCESS-
`(1) TIME TO FILE- A request for an independent external review
under this section shall be filed with the plan or issuer not later than 60
business days after the date on which the participant or beneficiary
receives notice of the denial under section 503A(b)(4) or the date on which
the internal review is waived by the plan or issuer under section
503A(b)(1)(D).
`(A) IN GENERAL- Subject to the succeeding provisions of this
subsection, a group health plan, and a health insurance issuer offering
health insurance coverage in connection with a group health plan,
may--
`(i) except as provided in subparagraph (B)(i), require that a
request for review be in writing;
`(ii) limit the filing of such a request to the participant or
beneficiary involved (or an authorized representative);
`(iii) except if waived by the plan or issuer under section
503A(b)(1)(D), condition access to an independent external review under
this section upon a final determination of a denial of a claim for
benefits under the internal review procedure under section
503A;
`(iv) except as provided in subparagraph (B)(ii), require
payment of a filing fee to the plan or issuer of a sum that does not
exceed $50; and
`(v) require that a request for review include the consent of
the participant or beneficiary (or authorized representative) for the
release of medical information or records of the participant or
beneficiary to the qualified external review entity for purposes of
conducting external review activities.
`(B) REQUIREMENTS AND EXCEPTION RELATING TO GENERAL RULE-
`(i) ORAL REQUESTS PERMITTED IN EXPEDITED OR CONCURRENT CASES-
In the case of an expedited or concurrent external review as provided
for under subsection (e), the request may be made orally. In such case a
written confirmation of such request shall be made in a timely manner.
Such written confirmation shall be treated as a consent for purposes of
subparagraph (A)(v).
`(ii) EXCEPTION TO FILING FEE REQUIREMENT-
`(I) INDIGENCY- Payment of a filing fee shall not be required
under subparagraph (A)(iv) where there is a certification (in a form
and manner specified in guidelines established by the Secretary) that
the participant or beneficiary is indigent (as defined in such
guidelines). In establishing guidelines under this subclause, the
Secretary shall ensure that the guidelines relating to indigency are
consistent with the poverty guidelines used by the Secretary of Health
and Human Services under title XIX of the Social Security
Act.
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