Major Provisions of S. 1 as Passed by the Senate, and H.R. 1, as Passed by the House

CRS Report for Congress
Regulatory Reform Provisions of S. 1,
as Passed by the Senate, and
H.R. 1, as Passed by the House
Updated July 23, 2003
Jennifer Boulanger and Sibyl Tilson
Specialists in Social Legislation
Domestic Social Policy Division

Congressional Research Service ˜ The Library of Congress

Regulatory Reform Provisions of S. 1, as Passed by the
Senate, and H.R. 1, as Passed by the House
Summary
On June 27, 2003, the Senate passed the Prescription Drug and Medicare
Improvement Act of 2003 by a vote of 76-21. Later that same evening, the House
passed the Medicare modernization and Prescription Drug Act of 2003 by a recorded
vote of 216-215 with one voting present.
Each of the bills contain numerous provisions regarding the Medicare
prescription drug benefit, the new MedicareAdvantage program, Medicare payment
and benefit changes, Medicare program administration, and regulatory reform,
appeals and contracting reform. This report provides a detailed side-by-side
comparison of the regulatory reform, appeals, and contracting reform provisions of
both S. 1 and H.R. 1.
Title V of S. 1 and Title IX of H.R. 1 would modify how Medicare regulations
and guidance are communicated; would modify the procedures used to resolve
payment disputes; and would establish various provider appeal processes, particularly
for those who face termination of Medicare participation or denial of their application
to participate in the program. As well as attempting to minimize Medicare’s
administrative burden, the bills address appeals issues; change Medicare’s authority
to contract for claims processing services; establish that these contracts be
competitively bid at least every 5 years in H.R. 1 and every 6 years in S. 1; and place
new requirements on the Medicare claims processing contractors, including an
increased emphasis on provider education. Other program changes, demonstration
projects, and mandated studies are also included in these titles. Many of the
provisions of these titles codify initiatives underway within the Centers for Medicare
and Medicaid Services (CMS), the agency that administers Medicare, under its
current authority. The proposed legislation authorizes increased funding but action
by the appropriations committees would be required for CMS to receive additional
money.
The Congressional Budget Office (CBO) has estimated that the added
administrative costs to the government in implementing the regulatory reform
provisions of S. 1 and H.R. 1 would be $4 billion over the FY2004 through FY2013
period. However, these are administrative costs that are subject to the appropriations
process rather than mandatory benefit spending. As a result, the appropriations
committees have discretion to determine the actual level at which any of the new
requirements would actually be funded. CBO also estimates that mandatory benefit
spending would be increased in S. 1 by almost $1 billion over the FY2004 through
FY2013 period (due to the change in procedures for appealing local coverage
determinations and the inclusion of additional funding in the mandatory Medicare
Integrity Program funding for provider education). Those provisions are not in H.R.

1 and CBO estimated that there was no increase in direct funding in that bill.

This report will be updated as events warrant.

Contents
In troduction ......................................................1
Overview ....................................................1
Side-by-Side Comparison of S. 1 and H.R. 1 Regulatory Reform Provisions....4
Subtitle A. Regulatory Reform...................................4
Subtitle B. Appeals Process Reform...............................6
Subtitle C. Contracting Reform.................................12
Subtitle D. Education and Outreach..............................13
Subtitle E. Review, Recovery, and Enforcement Review..............16
Subtitle F. Other Improvements.................................19

Regulatory Reform Provisions of S. 1,
as Passed by the Senate, and H.R. 1,
as Passed by the House
Introduction
Overview
For some time, observers have expressed concern over the way in which
Medicare has been administered. Some believe that the Centers for Medicare and
Medicaid Services (CMS, formerly the Health Care Financing Administration or
HCFA) has not been provided with sufficient resources, both staff and funding, or
management flexibility to enable it to carry out its ever increasing responsibilities.
Others believe that organizational shortcomings are exacerbated by a bureaucratic
approach emphasizing regulatory controls that adversely affect program
administration. The General Accounting Office (GAO) describes the agency as a
lightning rod attracting the criticism from those discontented with program policies
because of the number and diverse interests of its stakeholders (which run the gamut
from providers, including general and specialty physicians; hospitals; practitioners;
and medical suppliers, to beneficiaries and taxpayers), its responsibility to ensure
fiscal prudence, Medicare’s market dominance, and its very nature as a public
program. Moreover, Medicare, because of its sheer size and fragmented,
decentralized operations, is seen as highly vulnerable to fraud, waste, and abuse.¹
One of the central issues driving the debate over the effectiveness of Medicare’s
administration is the perception that the enforcement of Medicare’s payment rules
imposes too great a burden on health care providers and confuses Medicare
beneficiaries. Essentially, complaints about unreasonable demands for claims
documentation, contradictory billing instructions, excessive paperwork, and the sense
that providers and physicians are being unfairly investigated, if not prosecuted, over
purportedly innocent billing errors have prompted efforts to provide regulatory relief.
Title V of S. 1 and Title IX H.R. 1 would modify how Medicare regulations and
guidance are communicated; would modify the procedures used to resolve payment
disputes; and would establish various provider appeal processes, particularly for
those who face termination of Medicare participation or denial of their application
to participate in the program. As well as attempting to minimize Medicare’s
administrative burden, the bill would address appeals issues and would provide for

¹ U.S. General Accounting Office, Medicare: Successful Reform Requires Meeting Key
Management Challenges, GAO-01-1006, July 25, 2001 and Regulatory Issues for Medicare
Providers, GAO-01-802R, June 11, 2001 for additional information.

more competition in the way Medicare claims processing contractors are chosen.
Many of the provisions of the bill codify initiatives underway within the Centers for
Medicare and Medicaid Services (CMS), the agency that administers Medicare, under
its current authority.
The regulatory reform titles in these bills came from S. 3018 introduced at the
close of the 107^th Congress and H.R. 810 which was reported out of the House
Committee on Ways and Means and the Committee on Energy and Commerce. The
provisions of both those bills comprise Title V in S. 1 and Title IX of H.R. 1. A
number of bills were developed in the 107^th Congress. The precursor of all the
legislation was the Medicare Education and Regulatory Fairness Act (MERFA or
H.R. 868). MERFA was criticized by the Office of the Inspector General (OIG) in
HHS as potentially encouraging fraud, in part, because it would have granted
physicians immunity if they voluntarily returned overpayments when potentially
facing investigation. That provision was dropped in later legislation that passed the
House December 4, 2001, the Medicare Regulatory and Contracting Reform Act of
2001(H.R. 3391), which also incorporated changes suggested by the OIG, GAO and
the Department of Justice to ensure that the government’s ability to address Medicare
fraud, waste, and abuse would not be significantly weakened. Selected provisions
of H.R. 3391 were also incorporated into the Medicare Modernization and
Prescription Drug Act of 2002 (H.R. 4954) which passed the House on June 28,
2002. Similar legislation was introduced in the Senate: S. 452, the Medicare
Education and Regulatory Fairness Act of 2001 which was very similar to the
original House bill; S. 1738, the Medicare Appeals, Regulatory, and Contracting
Improvement Act of 2001 which incorporated similar concerns regarding the
government’s ability to address Medicare program integrity issues; and S. 3018, the
Beneficiary Access to Care and Medicare Equity Act of 2002 which contained
selected provisions from S. 1738. None of these bills came to a vote by the Senate.
H.R. 810 was introduced during the beginning of the 108^th Congress and was based
on H.R. 4954. The House Energy and Commerce Committee and the House Ways
and Means Committee reported out slightly different versions of Medicare regulatory
relief legislation on March 26, 2003 and on April 11, 2003, respectively.
A major feature of both S. 1 and H.R. 1 (and one ardently supported by the
Secretary of HHS) is contracting reform. The contracting reform provisions would
change Medicare’s authority to contract for claims processing services, another
central issue seen to complicate effective program administration. Presently there are
statutory limits on which entities may process Medicare claims. Generally, fiscal
intermediaries process claims from institutional providers and carriers process Part
B claims, including those submitted by physicians, durable medical equipment
suppliers, laboratories and other practitioners. The Medicare statute’s provider
nomination provision allows professional associations of hospitals and certain other
providers to choose claims processing intermediaries on behalf of their members; the
statute requires that CMS choose only health insurance companies as carriers.
Medicare regulations coupled with long-standing agency practices have limited the
way that contracts for claims administration services can be established. For
example, the contracts are cost-based and lack incentives for quality performance.
Both bills would generally allow for greater flexibility in contracting for Medicare
claims processing functions by permitting the Secretary to enter into contracts with

any qualified entity for any or all functions of a Medicare claims processing
contractor.²
The Congressional Budget Office (CBO) has estimated that the added
administrative costs to the government in implementing the regulatory reform
provisions of S. 1 and H.R. 1 would be $4 billion over the FY2004 through FY2013
period. However, these are administrative costs that are subject to the appropriations
process rather than mandatory benefit spending. As a result, the appropriations
committees have discretion to determine the actual level at which any of the new
requirements would actually be funded. CBO also estimates that mandatory benefit
spending would be increased in S. 1 by almost $1 billion over the FY2004 through
FY2013 period (due to the change in procedures for appealing local coverage
determinations and the inclusion of additional funding in the mandatory Medicare
Integrity Program funding for provider education). Those provisions are not in H.R.

1 and CBO estimated that there was no increase in direct funding in that bill.

This report provides a detailed side-by-side comparison of the regulatory reform,
appeals, education, and contracting reform provisions of both bills. It will be updated
as events warrant.

² For additional information, see U.S. General Accounting Office, Medicare Contracting
Reform: Opportunities and Challenges in Contracting for Claims Administration Services,
GAO-01-918, June 28, 2001 and Medicare: Comments on HHS’ Claims Administration
Contracting Reform Proposal, GAO-01-1046, Aug. 17, 2001. OIG testimony on the need
for contractor reform can be found at [http://oig.hhs.gov/testimony/2001/062801mm.pdf].

CRS-4
Side-by-Side Comparison of S. 1 and H.R. 1 Regulatory Reform Provisions
tle A. Regulatory Reform
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^d^e^ter^mⁱⁿ^{es th}^{at th}^{e tw}^o^-^th^ir^d^s^r^e^d^u^ctⁱ^oⁿ^is
ⁱⁿ^f^easib^{le, h}^e^w^o^u^l^d^b^e^r^e^q^u^ir^ed^toⁱⁿ^f^o^r^m
^C^oⁿ^g^r^es^sⁱⁿ^w^rⁱ^tⁱⁿ^g^by^Ju^l^y^{1, 2004 of}^t^h^e^reas^on^s
^an^d^t^h^en^estab^lish^{a f}^easib^{le r}^e^d^u^ctioⁿ^to^b^e
^achⁱ^e^v^e^{d by}^Jan^u^a^ry^{1, 2005.}

CRS-6
ppeals Process Reform
^Provisⁱ^ons^C^{urrent L}^a^w^S^{. 1}^H^{.R. 1}
^ans^f^e^r^of^Denⁱ^als^of^claim^s^f^o^{r Medicare pay}^m^en^{t m}^a^y^be^S^ecti^oⁿ^511.^T^h^e^Secretary^an^{d C}^o^m^mⁱ^s^sⁱ^on^{er of}^S^ectⁱ^o^{n 931.}^Sim^ilar^p^r^o^v^isioⁿ^r^e^g^a^r^dⁱⁿ^g
^s^pons^{ibility for}^appeal^{ed by}^ben^e^fi^cⁱ^ari^e^s^{(or prov}ⁱ^d^ers^w^h^{o are}^S^o^ci^al^S^ecu^ri^t^y^w^o^u^l^{d be requ}ⁱ^r^{ed t}^o^dev^e^l^{op an}^d^pl^an^s^u^bmⁱ^s^sⁱ^on^{, bu}^t^al^s^o^w^o^u^l^{d t}^r^an^s^f^{er t}^h^e
^e^di^car^e^appeal^s^repres^en^tin^g^th^{e ben}^e^fⁱ^ciary⁾^{or in}^certain^tr^an^sm^{it to}^Coⁿ^g^r^{ess a p}^l^an^f^o^r^tr^an^sf^er^rⁱⁿ^g^th^e^A^L^J^f^uⁿ^c^tioⁿ^f^r^o^m^SSA^to^{HHS w}^ithⁱⁿ^a
^circu^m^s^t^an^ces^{, prov}^iders^{or s}^u^ppliers^directly^.^T^h^e^f^uⁿ^c^tioⁿ^s^o^f^ad^mⁱⁿⁱ^str^a^tiv^{e law}^j^u^d^g^{es (}^A^L^J^s)^pres^{cribed tim}^ef^ram^e^{. T}^h^{e C}^o^m^mⁱ^s^sⁱ^on^{er of}
^th^ir^d^lev^e^{l o}^f^ap^p^{eal is to}^an^ad^mⁱⁿⁱ^str^a^tⁱ^v^{e law}^res^pon^sⁱ^{ble f}^o^{r h}^earin^g^cas^es^uⁿ^d^{er T}ⁱ^t^l^e^XVIII^SSA^an^{d th}^{e Secretary}^w^{ould be requ}^{ired to}
^j^u^dg^{e (A}^L^J^{). T}^h^e^ALJ^s^th^{at h}^{ear Medicare cas}^es^f^r^o^m^th^{e So}^{cial Secu}^r^ity^A^d^mⁱⁿⁱ^str^a^tioⁿ^to^HHSⁿ^o^d^e^v^e^lo^p^{a p}^l^an^to^tr^an^sf^er^th^{e f}^uⁿ^c^tioⁿ^s^o^f^th^e
^a^r^e^em^ploy^{ed by}^th^{e Social S}^e^c^u^rⁱ^t^y^l^a^t^e^{r t}^h^an^A^p^ri^l^{1, 2004. T}^h^{e p}^l^aⁿ^w^o^ul^{d i}ⁿ^cl^u^d^e^A^L^Js^w^h^{o a}^r^e^res^pon^sⁱ^bl^{e f}^o^{r h}^eariⁿ^g
^A^d^mⁱⁿⁱ^str^a^tioⁿ^{— a}^l^e^g^a^cy^f^r^o^m^th^{e in}^cep^tioⁿ^o^fⁱⁿ^f^o^r^m^a^tⁱ^oⁿ^oⁿ^{: w}^o^r^k^lo^ad^{, co}^{st p}^r^o^j^ectioⁿ^s^an^d^{Medicare cas}^es^f^r^om^SSA^{to HHS. T}^h^is^plan
^th^{e Medicare prog}^ram^w^h^en^{Medicare w}^a^s^part^of^fⁱⁿ^aⁿ^cⁱⁿ^g^,^tr^an^sitioⁿ^tim^eta^b^l^e^,^r^e^g^u^l^atioⁿ^s^,^w^o^u^l^d^b^e^d^u^{e to}^Coⁿ^g^r^{ess n}^o^{t later}^th^an
^{Social Secu}^rity^.^d^e^v^e^lo^p^m^en^{t o}^f^{a case tr}^ackⁱⁿ^g^sy^stem^{, f}^easib^ility^O^c^t^{ober 1, 2004. A}^G^A^O^ev^al^u^a^tⁱ^oⁿ^of^t^h^e
^o^f^p^r^eced^en^tⁱ^a^{l au}^th^o^r^ity^{, f}^easib^ility^o^f^electroⁿⁱ^c^pl^an^w^o^u^l^{d be du}^{e w}ⁱ^t^hⁱⁿ^{6 m}^oⁿ^t^h^s^of^t^h^e
^appeals^f^ilin^g^s^an^d^telecoⁿ^f^eren^ce,^s^t^epsⁿ^{eeded to}^pl^an^’^s^s^u^bmⁱ^s^sⁱ^on^.^A^L^{J f}^uⁿ^c^tⁱ^oⁿ^s^w^o^u^l^{d be}
ⁱ^{ki/CRS-RL31901}^en^s^u^{re th}^{e in}^depen^d^en^{ce o}^f^A^L^J^s⁽ⁱⁿ^c^lu^din^g^t^r^an^s^f^{erred n}^o^earlⁱ^e^{r t}^h^an^Ju^l^y^{1, 2005 an}^d
^g/w^en^s^u^rin^g^th^{e A}^L^J^s^{are in}^an^of^fⁱ^{ce f}^uⁿ^c^tion^a^lly^an^dⁿ^o^l^a^t^e^{r t}^h^an^O^c^t^{ober 1, 2005.}
^s^.or^o^p^er^atioⁿ^a^lly^sep^a^r^a^{te f}^r^o^m^th^{e Cen}^t^er^{s f}^o^r^T^h^{e Secretary}^w^o^u^l^{d be requ}^{ired to}^{place th}^e
^le^ak^Medicare^&^Medicaid^Serv^ices^an^{d th}^{e C}^eⁿ^t^{er f}^o^r^A^L^J^sⁱⁿ^aⁿ^admⁱⁿⁱ^s^t^rativ^{e of}^fⁱ^{ce th}^{at is}
^Medi^{care C}^h^oi^ces^{), g}^e^og^raphⁱ^c^di^s^t^ri^bu^tⁱ^oⁿ^of
^://wiki^A^L^Js^{, h}ⁱ^riⁿ^g^of^A^L^Js^{, perf}^orm^aⁿ^c^e^s^t^an^dards^of^A^L^J^s^{, s}^h^arin^g^res^o^u^r^ces^w^ith^S^o^{cial Secu}^rity^o^r^g^aⁿⁱ^zatioⁿ^a^lly^an^d^f^uⁿ^c^tioⁿ^a^lly^sep^a^r^a^te^f^r^om^th^{e C}^eⁿ^t^ers^f^o^{r Medicare &}^Medic^aⁱ^d
^h^ttp^r^e^ga^r^dⁱ^{ng A}^L^J^s^,^t^r^aⁱⁿⁱ^ng^aⁿ^d^r^e^c^o^m^m^e^nd^a^tⁱ^o^{ns fo}^r^S^e^rvⁱ^ces^{. Wou}^l^{d f}^u^rt^he^{r requ}ⁱ^r^{e t}^h^at^t^h^e
^fur^t^he^r^Co^ngr^e^ssi^oⁿ^a^l^a^c^tⁱ^o^n.^T^h^e^G^A^O^w^o^ul^d^b^e^A^L^Js^report^t^o^{, an}^{d be s}^u^pervⁱ^s^ed^b^y^,^t^h^e
^requⁱ^r^e^d^t^o^ev^alu^a^{te th}^{e Secretary}^’^s^an^d^Secretary^{or Depu}^ty^Secretary^an^{d n}^o^oth^e^r
^C^o^m^mⁱ^s^sⁱ^one^r^’^s^plan^{. Fu}^rth^e^{r, th}^{e Secretary}^an^d^o^f^fⁱ^{cial w}^ithⁱⁿ^th^{e Dep}^a^r^t^m^eⁿ^t^.
^C^o^m^mⁱ^s^sⁱ^on^{er cou}^l^dⁿ^o^{t im}^plem^en^{t th}^{e plan}^to
^tr^an^sf^er^th^{e A}^L^J^f^uⁿ^c^tⁱ^oⁿ^uⁿ^{til at least 6}^m^oⁿ^t^h^s^Wou^l^{d au}^t^h^o^rⁱ^{ze t}^o^{be appropri}^a^t^e^{d s}^u^ch
^af^ter^th^{e GA}^{O r}^e^p^o^r^t^s^u^m^s^as^ar^e^neces^s^a^ry^f^o^{r F}^Y^{2005 an}^{d each}
^s^u^bs^equ^eⁿ^t^fⁱ^s^{cal y}^{ear to in}^creas^{e th}^{e n}^u^m^ber
^of^A^L^Js^{, i}^m^prov^{e edu}^catⁱ^oⁿ^an^{d t}^r^aiⁿⁱ^ng^of
^A^L^J^s^an^{d to in}^creas^{e th}^{e s}^t^af^f^of^th^e
^D^e^p^a^r^t^m^e^nt^a^l^A^p^p^e^a^l^s^B^o^a^r^d⁽^t^he^fi^na^l^l^e^ve^l
^of^appeal^).

CRS-7
^Provisⁱ^ons^C^{urrent L}^a^w^S^{. 1}^H^{.R. 1}
^t^e^{d acces}^s^t^o^In^g^eⁿ^e^{ral, adm}ⁱⁿⁱ^s^t^r^a^tiv^{e appeals}^m^u^s^t^be^Se^c^tⁱ^oⁿ^512.^T^h^{e Secretary}^w^o^u^l^{d be requ}^ired^t^o^S^ecti^oⁿ^932.^Sam^e^prov^is^ion^ex^{cept rev}ⁱ^ew
^eview^e^xha^ust^e^d^p^rⁱ^o^r^t^o^j^u^dⁱ^cⁱ^a^l^r^e^vi^e^w^.^es^tablis^h^{a proces}^s^w^h^ere^a^provⁱ^d^er,^s^u^pplⁱ^e^{r, or a}^en^tity^w^o^u^l^d^b^e^d^e^fⁱⁿ^e^d^as^a³^-^m^e^m^b^er^p^aⁿ^e^l
^benefⁱ^ciary^m^a^y^obtain^acce^s^s^{to j}^u^{dicial rev}ⁱ^ew^c^o^nsi^s^tⁱⁿ^g^of^A^L^Js^{, m}^e^m^b^ers^of^t^h^e
^w^h^eⁿ^{a r}^e^vⁱ^ew^en^tity⁽^o^f^u^p^to^th^r^{ee q}^u^alif^ied^D^e^part^m^eⁿ^t^al^A^ppeal^s^Boar^{d (D}^A^B^{), or}
^revⁱ^ew^ers^drawⁿ^f^r^om^appeals^lev^e^ls^oth^e^{r th}^an^th^e^qu^alif^{ied in}^divⁱ^du^als^as^s^o^{ciated w}^ith^a
^r^e^d^e^ter^mⁱⁿ^atioⁿ^lev^e^l)^d^e^ter^mⁱⁿ^{es, w}^ithⁱⁿ⁶⁰^d^a^y^s^qu^alⁱ^fⁱ^e^{d i}ⁿ^depen^d^en^t^con^t^ract^or.
^o^f^a^co^m^p^{lete w}^r^itten^r^e^q^u^{est, th}^{at it d}^o^e^sⁿ^o^t^h^a^v^e
^th^{e au}^th^ori^t^y^t^o^{decide th}^{e qu}^es^tion^of^law^or
^reg^u^l^ation^an^{d w}^h^{ere m}^a^{terial f}^acts^{are n}^o^{t in}
^di^sp^ut^e^.^T^h^{e deci}^sⁱ^on^w^o^u^l^{d n}^o^t^{be s}^u^bj^ect^t^o
^revⁱ^e^w^b^y^th^{e Secretary}^.^In^teres^t^w^o^u^l^{d be}
^as^s^e^s^s^e^{d on}^an^y^am^ouⁿ^tⁱⁿ^con^t^rov^e^rs^y^an^{d w}^o^u^l^d
^{be aw}^{arded by}^t^h^{e rev}ⁱ^ewⁱ^ng^c^o^u^r^tⁱⁿ^f^a^v^o^{r of}^t^h^e
ⁱ^{ki/CRS-RL31901}^prev^ailin^g^party^.^T^h^is^ex^{pedited acces}^s^to^j^u^dicial^r^e^vⁱ^ew^w^o^u^l^d^b^e^p^e^r^m^itted^f^o^r^{cases w}^h^er^{e th}^e
^g/w^S^ecre^t^ary^di^{d n}^o^t^en^t^e^{r i}ⁿ^t^o^{or ren}^e^w^provⁱ^d^er
^s^.or^ag^reem^en^ts^.
^le^ak
^G^A^O^w^o^u^l^{d be requ}ⁱ^r^{ed t}^o^report^t^o^C^oⁿ^g^r^es^s^on^No^p^r^o^v^isioⁿ^r^e^g^a^r^dⁱⁿ^g^I^llin^oⁱ^{s Co}^uⁿ^c^{il case.}
^://wiki^th^{e acces}^s^of^{Medicare ben}^e^fⁱ^ciaries^and^he^alth
^h^ttp^{care prov}^iders^{to j}^u^{dicial rev}ⁱ^ew^of^actio^ns^o^f^th^e
^S^ecret^ary^an^{d H}^H^S^af^t^e^{r F}^e^bru^a^r^y^{29, 2000 (t}^h^e
^dat^e^of^t^h^{e deci}^sⁱ^on^of^Sha^l^a^l^a^{v. Il}^lⁱ^noi^s^C^ounci^l
^{on L}^{ong T}^e^r^m^C^a^r^e^{, Inc.}^{(529 U}^.^S^.^{1 (2000)).}
^t^e^{d r}^evi^ew^of^N^o^provⁱ^sⁱ^oⁿ^.^S^e^c^tⁱ^oⁿ^513.^T^h^{e Secretary}^w^o^u^l^{d be requ}^ired^to^S^ecti^oⁿ^932(d⁾^.^Su^b^s^t^aⁿ^tially^sim^ilar
ⁱⁿ^p^r^o^v^id^er^dev^e^l^{op an}^{d i}^m^pl^em^en^t^{a proces}^s^t^o^ex^pedi^t^e^p^r^o^v^isioⁿ^alth^o^u^g^h^d^r^a^f^t^e^d^dⁱ^f^f^er^en^tly^;
^eement^r^e^vⁱ^ew^f^o^r^cer^tain^r^e^m^e^dⁱ^{es im}^p^o^s^ed^ag^ain^s^{t sk}^illed^h^o^w^e^v^e^r^,^th^is^p^r^o^v^isioⁿ^w^o^u^l^dⁿ^o^{t in}^clu^d^e
^e^r^mⁱ^natⁱ^onsⁿ^u^r^sin^g^f^{acilities (}^S^NFs)ⁱⁿ^clu^dⁱⁿ^g^ter^mⁱⁿ^atioⁿ^o^f^suspen^sⁱ^on^ofⁿ^u^r^s^e^ai^{de t}^r^aiⁿⁱⁿ^g^prog^ram^s^.

^p^a^r^ticip^atioⁿ^,^im^m^e^dⁱ^ate^d^eⁿⁱ^{al o}^f^p^a^y^m^en^ts,
^im^m^e^dⁱ^{ate im}^p^o^s^itioⁿ^o^f^tem^p^o^r^ar^y^m^aⁿ^a^g^e^m^eⁿ^t^,
^an^{d s}^u^s^p^en^sⁱ^on^ofⁿ^u^r^s^e^ai^{de t}^r^aiⁿⁱⁿ^g^prog^ram^s^.

CRS-8
^Provisⁱ^ons^C^{urrent L}^a^w^S^{. 1}^H^{.R. 1}
^T^h^{e appropriation}^of^s^u^ch^s^u^m^s^asⁿ^{eeded f}^o^r
^F^Y²^{005 a}ⁿ^d^s^u^b^s^e^q^u^eⁿ^t^y^e^a^r^s^t^o^r^e^d^u^c^e^b^y⁵⁰^%
^th^{e av}^erag^e^tim^{e f}^o^{r adm}ⁱⁿⁱ^s^t^rativ^{e determ}ⁱⁿ^ation^s^,
^{to in}^creas^{e th}^{e n}^u^m^{ber of}^A^L^J^s^an^d^appellate^s^t^af^f
^{at t}^h^{e DA}^B^,^an^{d to edu}^{cate th}^es^{e j}^u^dg^es^an^{d th}^eir
^s^t^af^f^s^on^lon^g^-^term^{care is}^s^u^es^w^o^u^l^{d be}
^au^th^orized.
^o^c^e^{ss fo}^r^T^h^{e s}^t^at^u^t^{e proh}ⁱ^bⁱ^t^s^approv^al^of^nur^s^e^ai^de^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ^932(e).^T^h^e^Secretary^w^o^u^l^d^be
ⁱⁿ^sta^t^e^m^eⁿ^{t o}^f^tr^ainⁱⁿ^g^p^r^o^g^r^a^m^sⁱⁿ^sk^illedⁿ^u^r^sin^g^f^{acilities th}^at^requⁱ^r^{ed t}^o^dev^e^l^{op a process}^f^o^{r rei}ⁿ^s^t^atⁱⁿ^g
^oval^of^nur^s^e^ai^de^h^a^v^e^been^s^u^bj^{ect to ex}^ten^d^{ed s}^u^rv^ey⁽^t^ha^t^is^,^approv^al^ofⁿ^u^r^s^e^ai^{de t}^r^aiⁿⁱⁿ^g^prog^ram^s^t^h^at
ⁿⁱ^{ng pr}^ogr^am^s^fo^und^t^o^p^r^o^vⁱ^d^e^sub^s^t^a^nd^a^r^d^c^a^r^e⁾^,^ha^ve^ha^d^h^a^v^e^been^termⁱⁿ^{ated (bef}^{ore th}^{e en}^{d of}^the
^s^e^riou^s^s^aⁿ^c^tion^s^im^pos^{ed s}^u^c^h^as^larg^{e civ}ⁱ^l^m^aⁿ^d^at^or^y²^-^y^{ear di}^s^a^pprov^al^peri^{od) i}^f^t^h^e
ⁱ^{ki/CRS-RL31901}^m^oⁿ^e^y^p^eⁿ^a^{lties, o}^r^h^a^v^e^w^a^iv^er^{s f}^o^r^r^e^q^u^ir^ed^licen^s^e^{d n}^u^r^s^e^s^t^af^fⁱⁿ^g^.^T^h^{e s}^t^atu^t^{e m}^aⁿ^d^ates^a^2-^f^acility^h^a^s^c^o^m^eⁱⁿ^to^co^m^p^lian^{ce w}^ith^th^e^ap^p^lic^ab^{le r}^e^q^u^ir^em^en^{ts. T}^h^{is p}^r^o^v^isioⁿ
^g/w^y^ear^los^s^ofⁿ^u^r^s^e^{aide train}ⁱⁿ^g^prog^ramⁱⁿ^th^e^cas^e^w^o^u^l^{d appl}^y^on^l^yⁱ^f^t^h^{e bas}ⁱ^s^f^o^{r t}^h^{e l}^o^s^s^of
^s^.or^of^an^y^of^t^h^{e abov}^{e v}ⁱ^ol^atⁱ^oⁿ^s^.^trainⁱⁿ^g^w^a^s^th^e^as^s^e^s^s^m^en^{t of}^{a civ}^{il m}^oⁿ^e^y
^le^ak^pen^a^l^t^y^of^{$5,000 or m}^o^re.
^://wiki^sⁱ^ons^t^o^M^e^di^car^e^S^e^c^tⁱ^oⁿ^514(a).^A^90-^day^tⁱ^m^e^f^r^a^m^e^f^o^r^N^o^provⁱ^sⁱ^oⁿ^.
^h^ttp^s^pr^oces^s^:^com^p^letin^g^th^{e record in}^{a h}^earin^g^bef^o^re^aⁿ^A^L^J
^{or t}^h^{e D}^A^{B (w}ⁱ^t^h^ex^t^eⁿ^sⁱ^o^ns^{for g}^{ood cau}^s^e⁾
^w^o^u^l^{d be es}^t^a^blⁱ^s^h^e^d.
^mp^letin^g^th^e
^d

CRS-9
^Provisⁱ^ons^C^{urrent L}^a^w^S^{. 1}^H^{.R. 1}
^{e of}^m^e^di^cal^S^ecti^oⁿ^514(b⁾^.^B^eⁿ^e^fⁱ^ciaries^’^m^e^{dical r}^e^c^o^rds^S^ecti^oⁿ^933(b⁾^.^S^a^m^e^provⁱ^sⁱ^oⁿ^.
^d^s^w^o^u^l^{d be abl}^e^t^o^{be u}^s^{ed i}ⁿ^qu^alⁱ^fⁱ^e^{d i}ⁿ^depen^d^en^t
^con^t^ractors^(QIC^{) recon}^s^ideration^s^.
ⁱ^{ce r}^e^qui^r^e^m^e^nt^s^Se^cti^oⁿ^514(c).^{Notice of}^an^{d decis}ⁱ^on^s^fr^o^m^S^ecti^oⁿ^933(c).^Su^b^s^tan^tially^t^h^{e sam}^e
^M^e^di^car^e^appeal^s^d^e^t^e^r^mⁱⁿ^a^tⁱ^oⁿ^s^,^r^e^d^e^ter^mⁱⁿ^atioⁿ^s^{, r}^ecoⁿ^s^id^er^atioⁿ^s^,^provⁱ^sⁱ^oⁿ^,^wⁱ^t^h^mⁱ^{nor di}^f^f^e^ren^cesⁱⁿ^proces^s
^A^L^J^appeal^s^,^an^{d D}^A^{B appeal}^s^w^o^u^l^{d be}^requⁱ^r^ed^aⁿ^d^r^e^q^uⁱ^r^e^m^eⁿ^t^s^,^a^l^t^h^o^{ugh t}^h^e^r^e^a^r^e^d^r^a^f^tⁱⁿ^g
^t^o^{be w}^rⁱ^t^t^eⁿⁱⁿ^{a m}^aⁿⁿ^e^{r u}ⁿ^d^ers^t^an^dabl^{e t}^o^a^dⁱ^ffe^r^e^nc^e^s^.
^ben^e^fⁱ^ciary^an^{d th}^{at in}^clu^d^es^{, as}^appropriate,
^reas^on^s^f^o^{r t}^h^{e det}^e^rmⁱⁿ^a^tⁱ^oⁿ^{or deci}^sⁱ^on^{, f}^o^{r a}
^r^e^d^e^ter^mⁱⁿ^atioⁿ^an^ex^p^l^aⁿ^a^t^ioⁿ^o^f^th^{e m}^e^dⁱ^{cal o}^r
^scien^tif^{ic r}^a^tioⁿ^a^{le f}^o^r^th^{e d}^ecisioⁿ^{, an}^d^th^e^p^r^o^cess
^f^o^{r f}^u^rt^h^e^{r appeal}^.
ⁱ^{ki/CRS-RL31901}^ib^ility^S^ecti^oⁿ^514(d⁾^.^Elig^ib^ility^r^e^q^u^ir^em^en^{ts w}^o^u^l^d^b^e^S^ecti^oⁿ^933(d⁾^.^Su^b^s^tan^tially^th^{e sam}^e
^g/w^qui^r^e^m^e^nt^s^of^Q^I^C^s^clarif^ied^f^o^{r qu}^alif^{ied in}^depen^d^en^{t con}^t^ractors^an^d^p^r^o^vⁱ^sⁱ^o^n,^a^l^t^h^o^{ugh t}^h^e^r^e^a^r^e^d^r^a^f^tⁱⁿ^g
^s^.or^th^ei^{r rev}ⁱ^ew^{er em}^ploy^eesⁱⁿ^clu^dⁱⁿ^g^m^e^{dical an}^d^dⁱ^ffe^r^e^nc^e^s^.^T^h^e^p^r^o^vⁱ^sⁱ^o^{n w}^o^ul^d^no^t^c^h^a^nge
^le^ak^l^e^ga^l^e^x^p^e^r^tⁱ^s^{e, i}ⁿ^depen^d^en^{ce requi}^r^e^m^e^nt^s,^th^{e elig}^ib^ility^r^e^q^u^ir^em^eⁿ^{ts o}^f^QI^{Cs to}
^p^r^o^h^ib^itioⁿ^oⁿ^co^m^p^en^satioⁿ^b^eⁱⁿ^g^lin^k^e^d^to^ex^p^licitly^p^e^r^m^it^p^eer^r^e^vⁱ^ew^o^r^g^aⁿⁱ^zatioⁿ^s^to
^://wiki^decisⁱ^on^s^r^eⁿ^d^{ered. P}^{eer rev}ⁱ^ew^org^aⁿⁱ^zation^s^se^r^v^e^.
^h^ttp^w^o^u^l^d^b^e^ex^p^licitly^p^e^r^m^itted^to^b^e^QI^Cs.^W^o^u^l^d
^redu^{ce t}^h^{e re}^q^uⁱ^r^{ed n}^u^m^{ber of}^Q^I^C^s^f^r^om^{12 t}^o
^fo^ur^.
^m^pl^em^ent^a^tⁱ^{on of}^S^e^c^tⁱ^oⁿ^514(e⁾^.^T^h^{e ef}^f^ectiv^{e date of}^certain^N^o^provⁱ^sⁱ^oⁿ^.
ⁱⁿ^Ben^e^fits^appeal^s^provⁱ^sⁱ^o^ns^w^o^u^l^{d be del}^a^y^e^{d u}ⁿ^tⁱ^l
^pr^ovem^ent^and^Decem^{ber 1}^,^{2004. Ex}^{pedited determ}ⁱⁿ^ation^s
^ot^ectⁱ^{on Act}^of²⁰⁰⁰^w^o^u^l^{d be delay}^e^{d u}ⁿ^{til Oc}^t^o^b^e^{r 1, 2003. P}^eer
^I^P^A⁾^re^fo^rms^r^e^vⁱ^ew^o^r^g^aⁿⁱ^za^tⁱ^oⁿ^s⁽ⁿ^o^w^c^a^l^l^e^d^q^u^ality
^im^prov^em^en^{t org}^aⁿⁱ^zation^s^by^th^{e Se}^cretary⁾
^w^o^u^l^d^,^oⁿ^{a tr}^aⁿ^sitioⁿ^a^{l b}^a^{sis, co}ⁿ^d^u^c^{t ex}^p^e^d^ited
^d^e^ter^mⁱⁿ^atioⁿ^s^uⁿ^{til th}^{e QI}^{Cs ar}^{e o}^p^e^r^a^tioⁿ^a^l.
^e^qui^rⁱ^{ng f}^u^l^l^and^New^ev^iden^{ce can}^{be pres}^en^{ted at an}^y^s^t^ag^{e of}^th^e^N^o^provⁱ^sⁱ^oⁿ^.^Se^c^tⁱ^o^{n 933(a).}^A^provⁱ^d^{er or}^s^u^pplⁱ^e^r
^l^{y pr}^es^{entation of}^appeals^proces^s^.^w^o^u^l^d^b^e^prohⁱ^bⁱ^t^e^{d f}^r^om^pres^en^tⁱⁿ^g^an^y
^dence^ev^iden^ceⁱⁿ^appeals^th^{at w}^a^sⁿ^o^{t pres}^en^ted^at
^th^{e q}^u^alif^iedⁱⁿ^d^e^p^eⁿ^d^en^{t co}ⁿ^t^r^acto^r^lev^e^l,
^uⁿ^l^es^s^th^{ere w}^a^s^g^ood^cau^s^e^f^o^{r n}^o^t
^pres^en^tin^g^th^{e ev}^iden^ce.

CRS-10
^Provisⁱ^ons^C^{urrent L}^a^w^S^{. 1}^H^{.R. 1}
^S^e^c^tⁱ^oⁿ⁵¹⁴^(g).^S^ectⁱ^oⁿ⁵¹⁴^provⁱ^sⁱ^oⁿ^s^a^r^e^S^ecti^oⁿ^933(d⁾^(4).^QI^{C elig}^ib^ility
^ef^f^ectiv^{e as}^if^en^{acted in}^B^I^P^A^.^requ^irem^en^ts^an^{d rev}ⁱ^ew^e^r^e^lⁱ^gⁱ^bⁱ^l^ity
^requ^irem^en^ts^w^o^u^l^{d be ef}^f^ectiv^{e as}^if^en^acted
ⁱⁿ^B^I^P^A
^arⁱ^{ng r}ⁱ^ght^s^r^e^l^a^t^e^d^Un^d^e^r^ad^mⁱⁿⁱ^str^a^tiv^{e au}^th^o^r^{ities, CMS h}^a^s^S^ecti^oⁿ^515.^T^h^{e Secretary}^w^oul^d^{be requ}^{ired to}^S^ecti^oⁿ^936.^Sa^m^e^p^r^o^vⁱ^sⁱ^o^n,^a^l^t^h^o^{ugh t}^h^e^r^e
^sⁱ^ons^{by t}^h^e^estab^lish^e^d^p^r^o^v^id^er^en^r^o^llm^en^{t p}^r^o^{cesses in}^dev^e^l^{op a t}ⁱ^m^e^lⁱⁿ^{e f}^o^{r act}ⁱ^oⁿ^on^Medi^care^{are draf}^tin^g^dif^f^e^ren^ces^.
^et^ar^{y t}^o^{deny or}ⁱⁿ^str^u^ctioⁿ^s^to^th^{e co}ⁿ^t^r^act^ors^.^A^provⁱ^d^{er den}ⁱ^ed^en^r^o^llm^en^{t ap}^p^licatioⁿ^s^an^d^{a proces}^s^f^o^{r prov}ⁱ^d^ers
^r^e^new^{a M}^e^di^car^e^a^p^r^o^v^id^er^ag^r^eem^en^{t is en}^titled^to^{a h}^earⁱⁿ^g^b^y^th^e^{to appeal den}ⁱ^als^{or n}^oⁿ^-^ren^e^w^a^ls^of^en^rollm^en^t
^o^{llment agr}^eement;^Secretary^.^application^s^{. T}^h^{e S}^e^cretary^w^o^u^l^{d be requ}^{ired to}
^ul^t^a^tⁱ^{on bef}^o^r^e^con^s^u^l^t^wⁱ^t^h^provⁱ^d^ers^an^{d s}^u^pplⁱ^e^rs^bef^o^re
^{ng pr}^ovi^d^er^ch^an^gⁱⁿ^g^th^{e prov}^{ider en}^rollm^en^{t f}^o^rm^s^.
^o^{llment agr}^eement
ⁱ^{ki/CRS-RL31901}^s^{by pr}^ovi^d^er^s^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ^516.^W^o^u^l^{d requ}^{ire th}^{e Secreta}^r^y^t^o^N^o^provⁱ^sⁱ^oⁿ^.
^g/w^{en t}^h^er^{e i}^s^{no ot}^her^permⁱ^t^{a provi}^{der or s}^u^pplⁱ^e^{r t}^o^appealⁱⁿ^t^h^{e cas}^e
^s^.or^t^y^avai^l^abl^e^w^h^e^r^{e a ben}^e^fⁱ^ciary^dies^bef^o^{re as}^sⁱ^gⁿⁱⁿ^g^appeal
^le^ak^rⁱ^ght^s.
^://wiki^ovider^acces^s^to^On^ly^ben^e^fⁱ^ciaries^h^a^v^e^s^t^an^din^g^{to appeal local}^S^ecti^oⁿ^517.^T^h^{e p}^a^r^{ties th}^{at h}^a^v^e^stan^dⁱⁿ^g^to^N^o^provⁱ^sⁱ^oⁿ^.

^h^ttp^{of local}^age^cov^e^rag^e^decisⁱ^on^s^by^{Medicare con}^t^ractors^.^a^{ppeal local cov}^e^rag^e^decisⁱ^on^s^w^o^u^l^{d be ex}^pan^d^ed^{to in}^clu^d^{e prov}^iders^{or s}^u^ppliers^adv^e^rs^ely^af^f^ected
^e^r^mⁱ^natⁱ^ons^by^t^h^e^d^e^termⁱⁿ^ation^.^T^h^{e Secretary}^w^o^u^l^{d be}
^r^e^q^u^ir^ed^to^estab^lish^a^proces^s^w^h^ereby^{a prov}^ider
^{or s}^u^{pplier m}^a^y^requ^es^{t a local cov}^e^r^a^ge
^d^e^ter^mⁱⁿ^atioⁿ^uⁿ^d^e^r^cer^tain^cir^c^u^m^stan^{ces. T}^h^e
^provⁱ^sⁱ^oⁿ^w^o^u^l^d^au^t^h^ori^{ze t}^o^{be appropri}^a^t^e^d^s^u^ch
^s^u^m^s^asⁿ^eces^s^a^ry^{to carr}^y^ou^{t th}^{e prov}^is^ion^s
^abov^{e. A}^l^s^o^t^h^e^S^e^cretary^w^o^u^l^{d be requ}^{ired to}
^stu^d^y^an^d^r^e^p^o^r^{t to}^Coⁿ^g^r^ess^oⁿ^th^{e f}^easib^ility^an^d
^ad^vⁱ^sab^ility^o^f^r^e^q^u^irⁱⁿ^g^Medⁱ^car^{e co}ⁿ^t^r^acto^r^{s to}
^track^th^{e s}^u^bj^{ect an}^{d s}^t^atu^s^of^claim^s^denⁱ^als^th^at
^{are appealed an}^{d f}ⁱⁿ^a^{l determ}ⁱⁿ^ation^s^.

CRS-11
^Provisⁱ^ons^C^{urrent L}^a^w^S^{. 1}^H^{.R. 1}
^sⁱ^ons^t^o^appeal^s^B^I^P^A^revⁱ^s^e^{d th}^{e tim}^{e f}^r^am^es^f^o^{r Medicare}^S^ecti^oⁿ^518.^T^hⁱ^s^provⁱ^sⁱ^oⁿ^w^o^u^l^{d add 30 day}^s^t^o^N^o^provⁱ^sⁱ^oⁿ^.
^m^es^appeals^.^F^o^r^th^{e f}ⁱ^rs^{t lev}^e^{l of}^{appeal, th}^e^th^{e tim}^{e f}^r^am^{e f}^o^{r decidin}^g^an^appeal^at^each^of^th^e
^“^r^edetermⁱⁿ^a^tion^”^lev^e^{l, th}^{e tim}^{e f}^r^am^{e f}^o^r^fo^ur^l^e^ve^l^s^o^f^a^p^p^e^a^l^.
^deci^sⁱ^on^s^w^a^s^redu^{ced f}^r^om^{90 day}^s^f^o^{r a part}^A
^appeal^an^{d 45 day}^s^f^o^{r a part}^B^appeal^t^o^{30 day}^s^;
^f^o^r^th^e^secoⁿ^d^lev^e^{l, th}^{e “}^r^ecoⁿ^s^id^er^atioⁿ^”^lev^e^l,
^t^h^e^tⁱ^m^e^fr^am^{e w}^a^s^redu^{ced f}^r^om^{120 day}^s^f^o^{r a}
^part^{B appeal}^t^o^{30 day}^s^(t^hⁱ^sⁱ^s^{a n}^e^w^l^e^v^e^l^of
^ap^p^{eal f}^o^r^p^a^r^t^A^a^p^p^e^a^l^s⁾^{; f}^o^r^th^{e th}^ir^d^lev^e^l,
^appeals^bef^o^{re adm}ⁱⁿⁱ^s^t^rativ^e^law^j^u^dg^es^{, th}^{e tim}^e
^f^r^am^{e w}^a^{s r}^e^d^u^ce^d^f^r^o^mⁿ^o^tim^{e lim}^{it to}⁹⁰^d^a^y^s^;
^an^d^th^{e f}^o^u^r^th^lev^e^l,^ap^p^eals^b^e^f^o^r^e^th^{e Dep}^a^r^t^m^eⁿ^t
^A^ppeals^B^o^{ard, th}^e^tⁱ^m^e^f^r^am^{e w}^a^s^redu^{ced f}^r^om
ⁿ^o^tim^{e lim}^it^to⁹⁰^d^a^y^s^{. B}^I^P^A^also^p^r^o^v^id^ed^th^at
ⁱ^{ki/CRS-RL31901}^{a ben}^e^fⁱ^ciary^cou^l^{d “}^e^s^{calate” h}ⁱ^s^{or h}^e^{r appeal to}
^g/w^th^{e n}^e^x^t^lev^e^{l if}^th^{e ap}^p^eal^w^a^{s n}^o^{t d}^ecid^e^dⁱⁿ^a
^s^.or^tim^ely^f^a^sh^ioⁿ^.
^le^akⁱ^mⁱ^natⁱ^{on of}^BIPA^S^ectⁱ^oⁿ^{522 requ}ⁱ^r^e^s^t^h^at^appeal^s^of^l^o^cal^S^ecti^oⁿ^519.^T^h^e^st^a^t^ut^o^r^y^l^a^ngua^ge^t^h^a^t^r^e^q^uⁱ^r^e^s^N^o^provⁱ^sⁱ^oⁿ^.
^qui^r^e^m^e^nt^t^o^us^e^co^v^e^r^a^g^e^d^e^ter^mⁱⁿ^atioⁿ^s^b^e^h^ear^d^b^y^A^L^J^s^o^f^th^e^SSA^ALJ^s^{be u}^s^{ed to h}^{ear appeals}^of^local
^://wiki^c^ia^{l S}^ecu^rity^{Social Secu}^rity^A^d^mⁱⁿⁱ^s^t^ration^(SSA^{). A}^s^{a res}^u^lt,^co^v^e^r^a^g^e^d^e^ter^mⁱⁿ^atioⁿ^s^w^o^u^l^d^b^e^elimⁱⁿ^ated^.^T^h^e
^h^ttp^minⁱ^stra^tioⁿ^if^th^{e A}^L^J^f^uⁿ^c^tioⁿ^w^e^r^e^m^o^v^e^d^f^r^o^m^SSA^to^HHS,^r^e^q^u^irem^en^{t th}^{at th}^es^{e appeals}^{be h}^{eard by}^A^L^J^s
^mⁱⁿ^istra^{tive la}^w^th^es^{e local cov}^e^rag^e^determ^ina^t^ion^appeals^w^o^u^l^d^w^o^u^l^{d be ret}^aⁱⁿ^ed.
^{still n}^eed^to^b^e^h^ear^d^b^y^SSA^A^L^J^s^.
ⁱ^mⁱ^natⁱ^{on of}^BIPA^S^e^c^tⁱ^oⁿ^{521 requ}ⁱ^r^es^t^h^at^t^h^{e D}^e^part^m^eⁿ^t^al^S^ecti^oⁿ^520.^T^h^{e D}^A^{B w}^o^u^l^d^b^e^r^e^quⁱ^r^{ed t}^o^N^o^provⁱ^sⁱ^oⁿ^.

^qui^r^e^m^e^nt^f^o^r^de^A^ppeals^B^o^a^r^{d, th}^{e f}^o^u^r^th^lev^e^{l of}^{appeal, rev}ⁱ^ew^con^d^u^c^{t a rev}ⁱ^ew^o^f^t^h^{e decis}ⁱ^on^an^{d m}^a^k^e^a
^evi^ew^{by t}^h^e^appeals^cas^es^{de n}^o^vo^{. P}^r^io^r^to^B^I^P^A^{, th}^{e DA}^B^decisⁱ^on^{or rem}^aⁿ^d^th^{e appeal t}^o^th^{e A}^L^J^w^ithⁱⁿ
^par^t^m^ent^a^l^Appeal^s^review^{ed appeals}^bas^e^{d on}^th^{e record es}^tablis^h^e^d^t^h^{e 90-}^day^peri^od.
^d^du^rin^g^th^{e prev}^iou^s^th^{ree lev}^e^ls^of^appeal.

CRS-12
tle C. Contracting Reform
^Provisⁱ^ons^C^{urrent L}^a^w^S^{. 1}^H^{.R. 1}
^crea^sed^flexib^{ility in}^T^h^{e Secretary}^is^r^e^q^u^ired^to^coⁿ^t^r^{act w}^ith^h^ealth^Se^c^tⁱ^oⁿ^521.^A^dds^S^ectⁱ^oⁿ^1874A^t^o^t^h^{e S}^o^ci^a^l^S^ecti^oⁿ^911.^Sam^e^prov^is^ion^s^{, ex}^cept
ⁱ^ca^reⁱⁿ^s^u^ran^{ce com}^p^an^ies^{to proces}^s^an^d^pay^Medicare^S^e^c^u^r^ity^A^c^{t p}^e^r^m^ittin^g^th^e^S^e^c^r^e^t^a^r^y^t^o^con^t^racts^m^u^s^t^{be recom}^p^{eted at leas}^t^oⁿ^ce
^mⁱⁿ^istra^tioⁿ^P^a^{rt B}^claim^s^an^{d m}^a^y^{accept th}^{e n}^o^mⁱ^na^tion^of^co^m^p^etitiv^ely^coⁿ^t^r^{act w}^ith^an^y^elig^ib^{le en}^tity^to^ev^er^y⁵^y^ear^{s. Co}^m^p^etitiv^{e b}ⁱ^d^dⁱⁿ^g^f^o^r^th^e
^h^o^sp^{itals f}^o^r^en^{tities to}^p^r^o^{cess an}^d^p^a^y^th^eir^s^e^r^v^e^as^{a Medicare con}^t^{ractor (called “}^M^edicare^M^A^{Cs m}^u^st^b^e^gi^{n fo}^r^a^nnua^l^c^o^nt^r^a^c^t^p^e^rⁱ^o^d^s
^{Medicare claim}^s^.^A^d^mⁱⁿⁱ^s^t^rativ^{e C}^oⁿ^t^ractors^”^(MA^C^s⁾⁾^aⁿ^d^t^h^at^begⁱⁿ^on^{or af}^t^e^{r O}^c^t^{ober 1, 2010.}
^elimⁱⁿ^{ates th}^{e d}ⁱ^stin^ctioⁿ^b^e^tw^een^P^a^r^t^A
^con^t^ractors^an^d^P^a^rt^B^con^t^ractors^.^T^h^{e Secretary}
^m^a^y^r^e^ne^w^t^h^e^s^e^c^oⁿ^t^r^a^c^t^{s a}^nnua^l^l^y^fo^r^up^t^o⁶
^y^ears^.^A^{ll con}^t^racts^m^u^s^t^{be recom}^p^e^t^e^d^a^t^leas^t
^ev^er^y⁶^y^ear^{s. Fed}^e^r^a^{l A}^c^q^u^isitioⁿ^Reg^u^l^atioⁿ^s
^(FA^R^{) w}^o^u^l^{d apply}^{to th}^es^{e con}^t^racts^ex^{cept to th}^e
^ex^ten^t^an^y^p^r^o^v^isioⁿ^s^ar^{e in}^coⁿ^s^isten^t^w^ith^a
ⁱ^{ki/CRS-RL31901}^s^p^ecifⁱ^{c Medicare requ}^irem^en^{t, in}^clu^dⁱⁿ^gⁱⁿ^cen^tiv^e^coⁿ^t^r^{acts. Co}^m^p^etitiv^{e b}ⁱ^d^dⁱⁿ^g^f^o^r^th^{e MA}^{Cs m}^u^st
^g/w^b^e^gi^{n fo}^r^a^nnua^l^c^o^nt^r^a^c^t^p^e^rⁱ^o^d^s^t^h^a^t^b^e^gi^{n o}ⁿ^o^r
^s^.or^af^t^e^{r O}^c^t^{ober 1, 2011.}
^le^ak^Cer^t^ain^ter^m^{s a}ⁿ^d^coⁿ^d^itioⁿ^s^o^f^th^{e co}ⁿ^t^r^actin^g^Lⁱ^ab^ility^o^f^cer^tif^yⁱⁿ^g^an^d^dⁱ^sb^u^r^sin^g^o^f^fⁱ^cer^{s an}^d
^://wiki^ag^reem^en^ts^fo^{r f}ⁱ^s^{cal in}^term^ediaries^(FIs^{) an}^d^carriers^{are s}^p^e^cⁱ^fi^{ed in}^th^{e Medicare s}^t^atu^t^e.^th^{e Medicare A}^d^mⁱⁿⁱ^s^t^rativ^{e C}^oⁿ^t^ractors^w^o^u^l^d^be^lim^{ited ex}^{cept in}^cas^es^of^reck^les^s^dis^r^eg^{ard or}^th^e
^h^ttp^M^e^dⁱ^c^a^r^e^r^e^gul^a^tⁱ^o^{ns c}^o^up^l^e^d^wⁱ^t^h^l^o^ng-st^aⁿ^dⁱ^ngⁱⁿ^ten^t^to^d^e^f^r^au^d^th^{e Un}^ited^States.^T^h^{is lim}^itatioⁿ
^ag^en^cy^practices^h^a^v^e^f^u^rth^e^{r lim}^ited^t^h^e^w^a^y^th^at^oⁿ^liab^ility^d^o^e^{s n}^o^{t lim}^{it liab}^ility^uⁿ^d^er^th^{e False}
^con^t^racts^f^o^r^claim^s^admⁱⁿⁱ^s^t^ration^s^e^rv^ices^can^be^Claⁱ^m^s^A^c^t.
^es^tablis^h^e^{d. T}^h^e^certif^yⁱⁿ^g^an^{d dis}^b^u^r^sⁱⁿ^g^of^fⁱ^cers^Cⁱ^rcu^m^s^t^an^ces^w^h^{ere con}^t^ractors^an^{d th}^eir
^o^f^c^oⁿ^t^r^a^c^t^o^r^s^aⁿ^d^t^h^e^c^oⁿ^t^r^a^c^t^o^r^s^,^a^s^eⁿ^t^ities,^a^r^e^em^pl^oy^ees^w^o^u^l^{d be i}ⁿ^demⁿⁱ^fⁱ^e^d^w^o^u^l^{d be}
^p^r^o^t^ected^f^r^o^m^liab^ility^f^o^r^p^a^y^m^en^{ts, ex}^cep^{t in}^th^e^es^tablis^h^e^{d, both}ⁱⁿ^th^{e con}^t^{ract an}^{d as}^th^e
^cas^{e of}^gr^o^s^s^neg^lig^en^{ce or in}^ten^t^{to def}^r^au^{d th}^e^Secretary^determⁱⁿ^es^appropriate.
^Un^{ited States}^.
^fo^rma^tioⁿ^secu^rity^N^o^provⁱ^sⁱ^oⁿ^.^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ^912.^{Medicare con}^t^ractors^w^o^u^l^d^be
^q^uⁱ^re^meⁿ^t^{s fo}^r^r^e^q^u^ir^ed^to^im^p^l^em^en^{t an}ⁱⁿ^f^o^r^m^atioⁿ
ⁱ^ca^re^s^ecu^rity^prog^ram^th^{at m}^eets^th^{e s}^a^m^e
^mⁱⁿ^istra^tive^requⁱ^r^em^en^t^s^as^t^h^os^{e i}^m^po^{sed on}^f^e^deral
ⁿ^t^ra^c^t^o^rs.^ag^en^cies^.

CRS-13
^Provisⁱ^ons^C^{urrent L}^a^w^S^{. 1}^H^{.R. 1}
^ovi^d^er^educatⁱ^{on and}^Medⁱ^car^e^’^s^p^r^o^vⁱ^d^e^r^ed^u^catioⁿ^activ^{ities ar}^{e f}^uⁿ^d^ed^S^ecti^oⁿ^531(a)^.^T^h^{e Secretary}^w^o^u^l^{d be requ}^ired^S^ecti^oⁿ^{921 (a)}^{. Sam}^e^p^r^o^v^isioⁿ^ex^cep^{t it}
^cal^as^sⁱ^s^t^ance^t^h^{rough t}^h^{e prog}^ram^m^aⁿ^a^g^e^m^eⁿ^t^appropri^a^tⁱ^oⁿ^to^c^o^o^r^dⁱ^na^te^the^e^d^uc^a^tio^na^l^a^c^tivitie^{s thr}^o^{ugh the}^als^o^w^o^u^l^{d requ}^{ire th}^{e Secretary}^{to s}^u^bm^{it a}
^aⁿ^d^t^h^r^o^{ugh E}^d^uc^a^tⁱ^o^{n a}ⁿ^d^T^r^aⁱⁿⁱ^{ng c}^o^m^p^oⁿ^eⁿ^t^o^f^Medic^a^r^e^con^t^ractors^{to m}^a^xⁱ^mⁱ^{ze th}^{e ef}^f^ectiv^en^es^s^r^e^p^o^r^t^t^o^C^oⁿ^g^r^es^s^by^O^c^t^{ober 1, 2004}
^th^{e Medicare In}^teg^r^ity^P^r^og^ram^(MIP^{). T}^h^{e s}^t^atu^t^e^of^edu^catⁱ^oⁿ^ef^f^o^rt^s^f^o^{r prov}ⁱ^d^ers^an^{d s}^u^pplⁱ^e^rs^.^des^c^ribin^g^an^{d ev}^aluatin^g^th^{e s}^t^eps^tak^eⁿ^to
^requ^ires^toll-^f^r^{ee lin}^es^th^{at ben}^e^fⁱ^ciaries^can^call^coordiⁿ^a^t^e^t^h^e^f^uⁿ^dⁱⁿ^g^of^provⁱ^d^{er edu}^catⁱ^oⁿ^.
^w^ith^q^u^estioⁿ^s^o^r^to^r^e^p^o^r^{t su}^sp^icio^u^s^b^{ills. Un}^d^e^r^di^natⁱ^{on of}
^ad^mⁱⁿⁱ^str^a^tiv^{e au}^th^o^r^ity^{, CMS r}^e^q^u^ir^{es th}^eⁱ^{on f}^undi^ng
^coⁿ^t^r^acto^r^{s to}^h^a^v^eⁱⁿ^terⁿ^{et sites}^an^d^to^r^e^sp^oⁿ^d^to
^w^r^ittenⁱⁿ^q^u^ir^ies.
^to^S^ecti^oⁿ^531(b⁾^{. T}^h^{e Secret}^a^r^y^w^o^u^l^{d be requ}^ired^S^ecti^oⁿ^921(b⁾^.^S^a^m^e^provⁱ^sⁱ^oⁿ^.
^pr^{ove cont}^r^a^ct^or^t^o^us^{e s}^p^ecifⁱ^{c claim}^s^pay^m^en^{t error rates}^(or
ⁱ^{ki/CRS-RL31901}^f^or^m^ance^sⁱ^mⁱ^l^a^{r m}^e^t^h^odol^og^y⁾^t^o^provⁱ^d^{e i}ⁿ^cen^tⁱ^v^es^f^o^r
^g/w^con^t^ract^o^r^s^{to im}^plem^en^t^ef^f^ectiv^{e edu}^cation^an^d^ou^treach^prog^ram^s^f^o^{r prov}^iders^an^{d s}^u^ppliers^.
^s^.or^T^h^{e GA}^{O w}^o^u^l^{d s}^t^u^d^y^th^{e adeq}^u^acy^of^th^e
^le^ak^m^e^t^hodol^og^y^an^{d m}^a^k^e^recom^m^eⁿ^d^atⁱ^oⁿ^s^t^o^t^h^e
^://wiki^Secretary^.^T^h^e^S^e^c^r^etary^w^o^u^l^{d be requ}^{ired to}^r^e^p^o^r^t^to^th^{e Co}ⁿ^g^r^{ess o}ⁿ^h^o^w^h^eⁱⁿ^ten^d^{s to}^u^s^{e th}^e
^h^ttp^m^e^th^odolog^yⁱⁿ^im^provⁱⁿ^g^edu^cation^an^{d ou}^treach
^an^{d w}^h^et^h^e^{r t}^h^{e m}^e^t^h^odol^og^yⁱ^s^{a bas}ⁱ^s^f^o^r
^perf^orm^aⁿ^{ce bon}^u^s^es^.
^pr^{oved pr}^ovi^d^er^S^e^c^tⁱ^oⁿ^531(c).^Iⁿ^c^r^e^a^s^e^d^fundⁱ^{ng w}^o^ul^d^b^e^S^e^c^tⁱ^oⁿ^921(d⁾^.^Wou^l^{d au}^t^h^ori^{ze t}^o^be
ⁱ^{on and t}^r^aiⁿⁱ^ng^prov^{ided f}^o^{r th}^{e M}^e^dⁱ^{care In}^teg^r^ity^P^r^og^ram^of^{appropriated $25 m}^illion^f^o^{r f}ⁱ^s^{cal y}^ears
^{$35 m}^illion^begⁱⁿⁿⁱⁿ^g^w^ith^{FY2004 f}^o^{r in}^creas^ed^{2005 a}ⁿ^d^{2006 an}^{d s}^u^ch^s^u^m^s^asⁿ^eces^s^a^ry
^provⁱ^d^e^r^an^{d s}^u^pplⁱ^e^{r edu}^catⁱ^oⁿ^.^A^l^s^o^w^o^u^l^d^f^o^{r s}^u^cceedin^g^fⁱ^s^{cal y}^ears^toⁱⁿ^creas^e
^r^e^q^u^ir^{e Med}ⁱ^car^{e co}ⁿ^t^r^a^c^t^o^r^{s to}^tak^eⁱⁿ^to^edu^catⁱ^on^a^{nd t}^r^aiⁿⁱⁿ^g^of^provⁱ^d^ers^an^d
^con^s^ideration^th^{e s}^p^ecialⁿ^eeds^of^s^m^al^l^provⁱ^d^ers^s^u^pplⁱ^e^rs^{. F}^uⁿ^d^s^w^o^u^l^{d al}^s^o^{be ab}^l^e^t^o^be
^o^r^su^p^p^lⁱ^e^r^s^w^h^eⁿ^c^o^nd^uc^tⁱ^{ng e}^d^uc^a^tⁱ^o^{n a}ⁿ^d^u^s^e^d^{to im}^prov^{e th}^{e accu}^racy^{, con}^s^is^ten^c^y^,
^tr^ainⁱⁿ^g^activ^{ities an}^d^p^e^r^m^{its p}^r^o^v^isioⁿ^o^f^an^{d t}ⁱ^m^elⁱⁿ^es^s^of^c^oⁿ^t^ract^{or res}^pon^s^e^s^.
^techⁿⁱ^{cal as}^sⁱ^s^t^an^ce.^{Medicare con}^t^ractors^w^o^u^l^{d be requ}^{ired to}
^tailo^r^ed^u^catioⁿ^an^d^tr^ainⁱⁿ^g^activ^{ities to}^m^eet
^t^h^{e n}^eeds^of^s^m^al^l^provⁱ^d^ers^{or s}^u^pplⁱ^e^rs^.

CRS-14
^Provisⁱ^ons^C^{urrent L}^a^w^S^{. 1}^H^{.R. 1}
^tⁱ^onal^pr^ovi^d^er^S^ecti^oⁿ^531(d⁾^.^{Medicare con}^t^ractors^w^o^ul^{d be}^S^ecti^oⁿ^921(f).^S^a^m^e^provⁱ^sⁱ^oⁿ^.
ⁱ^{on pr}^ovi^sⁱ^ons^pro^hⁱ^bⁱ^t^{ed f}^r^om^u^sⁱⁿ^g^{a record of}^atten^d^an^{ce (or}
ⁿ^oⁿ^-^atten^d^an^{ce) at edu}^cation^a^{l activ}^itⁱ^e^s^{to s}^e^lect
^o^r^tr^a^c^k^p^r^o^v^id^er^{s o}^r^su^p^p^lier^sⁱⁿ^coⁿ^d^u^c^tin^g^an^y
^t^y^{pe of}^au^di^t^{or prepay}^m^eⁿ^t^revⁱ^ew^.
^s^t^o^{and pr}^om^pt^{No s}^p^ecifⁱ^{c s}^t^atu^t^ory^provⁱ^sⁱ^oⁿ^.^T^h^{e Medicare}^S^ecti^oⁿ^532.^T^h^{e Secretary}^w^o^u^l^{d be requ}^{ired to}^S^ecti^oⁿ^921(c)^{. Sam}^e^prov^is^ion^.
^s^pons^es^f^r^om^s^t^atu^t^{e g}^eⁿ^e^rally^requ^ires^t^h^a^t^th^{e Medicare}^dev^e^{lop a proces}^s^f^o^{r Medicare con}^t^ractors^to
^e^di^car^e^cont^r^a^ct^or^s^c^o^nt^r^a^c^t^o^r^s^c^o^m^m^uⁿⁱ^{cate in}^f^o^rm^ation^abo^u^t^com^m^uⁿⁱ^{cate w}^ith^ben^e^fⁱ^ciaries^an^d^w^ith^prov^iders
^{Medicare adm}ⁱⁿⁱ^s^t^ration^.^aⁿ^d^s^u^ppliers^{. A}^l^s^o^requ^ires^{a clear, con}^c^is^e
^w^r^itten^r^e^sp^oⁿ^{se to}ⁱⁿ^q^u^ir^{ies w}^ithⁱⁿ⁴⁵^b^u^sin^e^ss
^day^s^{. T}^h^{e Secretary}^w^o^u^l^{d en}^s^u^re^t^h^a^t^Medicare
^con^t^ractors^prov^{ide a toll-}^f^r^{ee n}^u^m^{ber w}^h^ere
ⁱ^{ki/CRS-RL31901}^ben^e^fi^cⁱ^ari^e^s^,^provⁱ^d^ers^an^{d s}^u^pplⁱ^e^rs^can^obt^aiⁿ^b^illin^g^,^co^dⁱⁿ^g^,^claim^s^{, co}^v^e^r^a^g^e^an^d^o^t^h^e^r
^g/wⁱⁿ^f^o^rm^ation^.^T^h^{e Medicare con}^t^racto^r^s^w^o^u^l^{d be}
^s^.or^r^e^q^u^ir^ed^to^m^aⁱⁿ^tain^{a sy}^stem^f^o^r^id^en^tif^yⁱⁿ^g^t^h^e
^le^ak^s^t^af^f^pers^on^w^h^{o prov}ⁱ^d^edⁱⁿ^f^o^rm^atⁱ^oⁿ^an^d
^m^oⁿ^itorin^g^th^{e acc}^u^r^acy^{, con}^s^is^ten^c^y^an^d
^://wiki^tim^elin^es^s^ofⁱⁿ^f^o^rm^ation^prov^{ided. T}^h^{e Secretary}
^h^ttp^w^o^u^l^{d es}^tablis^h^s^t^an^dar^d^s^reg^a^rdin^g^accu^racy^,
^coⁿ^s^isten^c^y^,^an^d^tim^elin^{ess an}^d^w^o^u^l^d^ev^alu^a^te^th^e
^{Medicare con}^t^ractors^on^th^es^{e s}^t^a^ndards^.^W^o^u^l^d
^au^th^{orize to be ap}^p^r^{opriated s}^u^ch^s^u^m^s^as
ⁿ^eces^s^a^ry^.
ⁱ^{ance on gui}^dance^A^s^{a g}^eⁿ^e^{ral prin}^{ciple of}^la^w^,^t^h^a^t^ha^s^b^een^S^ecti^oⁿ^533.^If^{a prov}ⁱ^d^{er or s}^u^pplⁱ^e^{r f}^o^l^l^o^w^s^S^ecti^oⁿ^903(c).^S^a^m^e^provⁱ^sⁱ^oⁿ^.

^s^u^s^t^ain^e^{d by}^th^{e Su}^prem^{e C}^o^u^r^{t, a Federal}^w^r^itten^g^uⁱ^d^aⁿ^{ce p}^r^o^v^id^ed^b^y^t^h^e^Secr^etar^y^o^r^a
^g^o^v^e^rn^m^eⁿ^t^ag^en^{t can}^no^t^und^o^Federal^{Medicare con}^t^ract^{or w}^h^en^f^u^rn^is^hⁱⁿ^g^item^s^or
^go^ve^rⁿ^m^e^nt^st^a^t^ut^o^r^y^o^r^r^e^gul^a^t^o^r^y^l^a^w^.^ser^v^{ices o}^r^su^b^m^ittin^g^{a cla}ⁱ^m^an^d^th^{e g}^uⁱ^d^aⁿ^c^e
^w^a^sⁱⁿ^accu^{rate, th}^{e prov}^{ider or s}^u^{pplier w}^o^u^l^{d n}^o^t
^{be requ}ⁱ^r^{ed t}^o^repay^t^h^{e ov}^erpay^m^en^t^(uⁿ^l^es^s^t^h^e
ⁱⁿ^accu^{rate in}^f^o^rm^ation^w^a^s^du^e^{to a clerical or}
^techⁿⁱ^{cal operation}^a^{l error).}

CRS-15
^Provisⁱ^ons^C^{urrent L}^a^w^S^{. 1}^H^{.R. 1}
^e^di^car^e^pr^ovi^d^er^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ^534.^T^h^{e Sec}^r^e^t^a^r^y^w^o^u^l^{d be directed}^to^S^ecti^oⁿ^923.^Su^b^s^tan^tially^sim^ilar^p^r^o^v^isioⁿ^,
^buds^m^aⁿ^create^a^{Medicare P}^r^ov^{ider Om}^bu^ds^m^aⁿ^w^ithⁱⁿ^th^e^a^l^t^h^o^{ugh w}^o^ul^d^no^t^r^e^q^uⁱ^r^e^st^a^{ff t}^o^b^e
^Departm^eⁿ^t^of^Health^an^{d Hu}^m^aⁿ^Serv^ices^an^{d to}^prov^{ided. A}^l^s^o^w^o^u^l^{d es}^tablis^h^{a B}^eⁿ^e^fⁱ^ciary
^provⁱ^d^e^s^t^af^f^t^o^t^h^{e O}^m^bu^ds^m^aⁿ^.^T^h^e^O^m^bu^ds^m^aⁿ^O^m^bu^ds^m^a^{n t}^o^p^r^o^vⁱ^d^e^c^o^nfi^d^eⁿ^tⁱ^al
^w^o^u^l^{d prov}ⁱ^d^{e as}^si^st^an^{ce t}^o^provⁱ^d^ers^on^a^as^sⁱ^s^t^an^{ce to Medicare}^ben^e^fⁱ^ciaries^.^Section
^coⁿ^f^id^en^{tial b}^a^{sis. A}^u^th^o^r^iz^e^s^su^ch^su^m^s^as¹^w^o^u^l^{d es}^t^a^blⁱ^s^h^{a Ben}^e^fⁱ^ci^ary^O^m^bu^ds^m^aⁿ
ⁿ^eces^s^a^ry^{be appropr}ⁱ^a^t^e^{d f}^o^{r F}^Y^{2004 an}^dⁱⁿ^{Section 301}^.
^s^u^bs^equ^eⁿ^t^y^ears^.
ⁱ^cⁱ^a^r^y^out^r^e^ach^No^ex^p^licit^statu^t^o^r^yⁱⁿ^str^u^ctioⁿ^f^o^r^d^e^m^oⁿ^s^tr^atioⁿ^.^S^ecti^oⁿ^535.^T^h^{e Secret}^ary^w^o^u^l^{d be requ}^{ired to}^S^ecti^oⁿ^924.^S^a^m^e^provⁱ^sⁱ^oⁿ^.
^ons^t^r^atⁱ^{on pr}^ogr^am^A^s^sⁱ^s^t^an^{ce is}^cu^rren^tly^av^{ailable to ben}^e^fⁱ^ciaries^es^tablis^h^{a dem}^oⁿ^s^tration^prog^ram^w^h^{ere Medicare}
^t^h^r^o^{ugh 1}^-^800-^Medi^{care an}^{d t}^h^ro^{ugh t}^h^e^St^a^t^e^s^p^ecialis^ts^prov^ided^as^sⁱ^s^t^an^{ce to ben}^e^fⁱ^ciariesⁱⁿ^at
^Health^In^s^u^ran^{ce C}^o^uⁿ^s^elin^g^P^r^og^ram^s^w^h^{ich are}^leas^t^sⁱ^x^local^{Social Secu}^rity^of^fⁱ^ces^(tw^o^of^w^h^ich
ⁱ^{ki/CRS-RL31901}^m^aⁿ^d^{ated by}^th^{e s}^t^atu^t^e.^w^o^u^l^{d be located in}^ru^{ral areas}^).
^g/w
^s^.orⁱ^o^r^det^e^r^mⁱ^natⁱ^{on of}^Medⁱ^car^{e law}^p^r^o^h^ib^{its p}^a^y^m^en^{t f}^o^r^item^s^an^d^S^ecti^oⁿ^{535 (b}^).^A^dem^oⁿ^s^t^r^atⁱ^oⁿ^proj^ect^w^o^u^l^d^S^ecti^oⁿ^938.^T^h^{e Secretary}^w^o^u^l^d^be
^le^ak^age^s^e^rv^ices^th^{at are n}^o^{t m}^e^dically^reas^on^a^b^{le an}^d^{be es}^tablis^h^e^{d by}^th^{e Secretary}^t^o^tes^t^th^e^r^e^q^u^ir^ed^to^estab^lish^{a p}^r^o^{cess w}^h^e^r^e
^neces^s^a^ry^f^o^{r th}^{e diag}ⁿ^o^sⁱ^s^{or treatm}^eⁿ^t^o^f^aⁿ^ad^mⁱⁿⁱ^str^a^tiv^{e f}^easib^ility^o^f^p^r^o^v^idⁱⁿ^g^{a p}^r^o^{cess f}^o^r^p^h^y^s^ic^ian^s^an^d^b^eⁿ^e^fⁱ^ciar^{ies can}^estab^lish^if
^://wiki^illn^ess^o^r^aⁿⁱⁿ^j^u^r^y^{. Un}^d^e^r^cer^tain^cir^c^u^m^stan^ces,^ben^e^fⁱ^ciaries^an^{d prov}^iders^{to requ}^es^{t an}^{d receiv}^e^{Medicare cov}^e^rs^certain^item^s^an^{d s}^e^rv^ices
^h^ttp^h^o^w^e^v^e^r^,^M^e^dⁱ^car^{e w}^{ill p}^a^y^f^o^rⁿ^oⁿ^c^o^v^er^ed^a^d^e^ter^mⁱⁿ^atioⁿ^{as to}^w^h^eth^e^r^th^{e item}^o^r^ser^v^ice^is^bef^o^{re th}^{e s}^e^rv^ices^{are prov}^ided.^A^GA^O
^s^e^rvⁱ^ces^t^h^at^ha^{ve been}^provⁱ^d^{ed i}^f^bot^h^t^h^e^cov^e^{red u}ⁿ^d^{er M}^e^dⁱ^{care by}^reas^on^s^of^m^e^dical^report^w^o^u^l^d^{be requ}ⁱ^r^{ed w}ⁱ^t^hⁱⁿ^{18 m}^oⁿ^t^h^s^of
^ben^e^fⁱ^ciary^an^{d th}^{e prov}^{ider of}^th^e^s^e^rv^ices^{did n}^o^tⁿ^ecessit^y^,^b^e^f^o^r^e^th^{e item}^o^r^ser^v^{ice in}^v^o^lv^ed^is^p^r^o^g^r^a^m^im^p^l^em^en^tatioⁿ^.

^kⁿ^o^w^an^{d cou}^l^{d n}^o^{t h}^a^v^e^reas^on^ably^been^ex^pected^f^u^rⁿ^ish^e^d^to^th^{e b}^eⁿ^e^fⁱ^ciar^y^.
^t^o^kⁿ^o^w^t^h^at^Medi^{care pay}^m^en^t^w^o^u^l^{d n}^o^t^{be m}^a^de
^f^o^{r th}^es^{e s}^e^rv^ices^.

CRS-16
^Provisⁱ^ons^C^{urrent L}^a^w^S^{. 1}^H^{.R. 1}
^al^l^pr^ovi^d^er^N^o^provⁱ^sⁱ^oⁿ^.^N^o^provⁱ^sⁱ^oⁿ^.^S^e^c^tⁱ^oⁿ^922.^A^d^e^m^o^nst^r^a^tⁱ^oⁿ^p^r^og^ram
^cal^as^sⁱ^s^t^ance^w^o^u^l^{d be es}^t^a^b^lⁱ^s^h^e^{d f}^o^{r th}^{e con}^t^ractors^to
^ons^t^r^atⁱ^{on pr}^ogr^am^prov^ide^techⁿⁱ^ca^l^a^s^sⁱ^s^t^aⁿ^c^e^to^s^m^all
^provⁱ^d^ers^an^{d s}^u^pplⁱ^e^rs^{, w}^h^en^requ^es^t^e^{d, t}^o
ⁱ^m^p^r^o^v^e^c^o^m^p^lⁱ^aⁿ^{ce w}ⁱ^th^Medicare
^requ^irem^en^ts^{. If}^errors^w^e^{re f}^o^uⁿ^d^{, th}^e
^con^t^ract^ors^w^o^u^l^d^{be barred f}^r^om^recov^e^riⁿ^g
^an^y^ov^erpay^m^en^ts^if^certain^requ^irem^en^ts^are
^m^e^{t an}^{d b}^a^r^rⁱⁿ^g^ev^iden^{ce of}^f^r^au^{d. A}^GA^O
^stu^d^y^w^o^u^l^d^b^e^r^e^q^u^ir^edⁿ^o^{t later}^th^an²^y^ear^s
^af^ter^th^{e d}^e^m^oⁿ^s^tr^atioⁿ^p^r^o^g^r^a^m^b^e^gⁱⁿ^s^.
^W^o^u^l^{d au}^th^{orize $1 m}^illionⁱⁿ^{FY2005 an}^d
ⁱ^{ki/CRS-RL31901}^$6^m^illi^onⁱⁿ^F^Y^{2006 t}^o^c^oⁿ^d^u^c^t^t^h^e^d^e^m^oⁿ^s^tr^atioⁿ^.
^g/w
^s^.or
^le^akbtitle E. Review, Recovery, and Enforcement Review
^://wiki^Provisⁱ^ons^C^{urrent L}^a^w^S^{. 1}^H^{.R. 1}
^h^ttp^{epayment r}^eview^No^ex^p^{licit statu}^t^o^r^yⁱⁿ^str^u^ctioⁿ^.^Un^d^e^r^ad^mⁱⁿⁱ^str^a^tiv^{e au}^th^o^r^{ities, CMS}^h^a^sⁱⁿ^str^u^cted^th^e^S^ecti^oⁿ^541.^T^h^{e con}^d^u^c^t^of^ran^dom^prepay^m^eⁿ^t^r^e^vⁱ^ew^w^o^u^l^{d be l}ⁱ^mⁱ^t^e^{d t}^o^on^l^y^t^h^os^{e don}^eⁱⁿ^S^ecti^oⁿ^934.^T^h^{e u}^s^e^of^ran^dom^prepay^m^eⁿ^t^revⁱ^ew^s^by^{Medicare con}^t^ractors^w^o^u^l^{d be}
^con^t^ractors^{to u}^s^{e ran}^dom^prepay^m^eⁿ^t^revⁱ^ew^s^to^acco^rdan^{ce w}^ith^s^t^an^{dard protocol dev}^e^{loped by}^lim^ited^to^oⁿ^ly^d^e^v^e^lo^pⁱⁿ^g^{a co}ⁿ^t^r^acto^r^-^w^id^e
^dev^e^l^{op con}^t^ract^or-^wⁱ^d^{e an}^{d prog}^ram^-^wⁱ^{de error}^th^{e Secretary}^.^Non^-^ran^dom^r^e^vi^ew^s^w^o^u^l^{d be}^{or prog}^ram^-^wⁱ^{de error ra}^t^e^{or u}ⁿ^d^{er s}^u^ch
^r^a^tes.^Noⁿ^-^r^aⁿ^d^o^m^p^a^y^m^en^{t r}^e^vⁱ^ew^{s ar}^{e p}^e^r^m^itted^prohⁱ^bⁱ^t^e^{d u}ⁿ^l^es^s^t^h^{ere i}^s^{a l}ⁱ^k^elⁱ^h^{ood of}^s^u^s^t^aiⁿ^e^d^ad^d^itioⁿ^a^{l cir}^c^u^m^stan^{ces p}^r^o^v^id^ed^uⁿ^d^er
ⁱⁿ^cer^tain^cⁱ^r^c^u^m^stan^{ces laid}^o^u^{t in}ⁱⁿ^str^u^ctioⁿ^s^to^{or h}ⁱ^g^h^l^e^v^e^l^of^pay^m^en^t^{error (}^a^s^d^e^fiⁿ^e^{d by}^t^h^e^reg^u^l^ation^an^{d in}^accor^d^an^{ce w}^ith^s^t^an^dard
^th^{e con}^t^ractors^.^Secretary⁾^an^{d w}^o^u^l^d^r^e^q^u^{ire th}^{e Secretary}^to^prot^ocol^dev^e^l^{oped by}^t^h^{e S}^e^c^r^et^ary^.
^estab^lish^p^r^o^t^o^c^o^l^{s f}^o^r^ter^mⁱⁿ^atin^g^th^eⁿ^oⁿ^-^r^aⁿ^d^o^m^N^oⁿ^r^aⁿ^dom^pay^m^en^t^revⁱ^ew^s^w^o^u^l^{d be}
^revⁱ^ew^s^.^p^e^r^m^itted^oⁿ^ly^uⁿ^d^er^cer^tain^cir^c^u^m^stan^ces.
^{y of}^No^ex^p^{licit sta}^t^u^t^o^r^yⁱⁿ^s^t^r^u^c^tⁱ^oⁿ^.^Un^d^e^r^S^ecti^oⁿ^542.^Wou^l^{d add n}^e^w^s^u^bs^ectⁱ^oⁿ^t^o^1874A^{Section 935}^.^W^o^u^l^{d add n}^e^w^s^u^bs^ectⁱ^oⁿ^t^o
^paym^e^nt^s^ad^mⁱⁿⁱ^str^a^tiv^e^au^th^o^r^ities,^C^M^Sⁿ^e^g^o^tⁱ^a^tes^th^at:^(h⁾⁽¹⁾^W^o^u^l^{d requ}^{ire es}^tablis^h^m^en^{t of}^{at leas}^t^{1893 t}^h^at^:^(f)(1)^Sim^ilar^p^r^o^v^isioⁿ^.^W^o^u^l^d
^{ended r}^e^paym^e^nt^ex^ten^d^{ed repay}^m^en^{t plan}^s^w^ith^prov^iders^th^{at n}^eed^a¹^-^y^ear^r^e^p^a^y^m^en^{t p}^l^an^{— b}^u^{t n}^o^{t lo}ⁿ^g^e^r^th^an³^requ^{ire tha}^t^{, in}^cas^es^of^h^a^rds^h^{ip, ex}^ten^d^ed
^ad^d^itioⁿ^a^{l tim}^{e to}^r^e^p^a^y^Medⁱ^car^{e o}^v^er^p^a^y^m^en^ts.^y^ears^{— w}^h^en^a^p^r^o^v^{ider requ}^es^ts^{a repay}^m^en^t^r^e^p^a^y^m^eⁿ^t^p^l^aⁿ^s^b^e^gi^ve^{n r}^a^ngi^{ng fr}^o^m⁶
^plan^{, u}ⁿ^l^es^s^th^{e Secretary}^believ^e^s^th^{e prov}^ider^m^oⁿ^t^h^s^aⁿ^d^u^p^t^o⁵^y^e^a^r^s^.^Iⁿ^c^a^s^e^s^o^f
^m^a^y^declare^ban^k^r^u^p^tcy^.^If^{a prov}^{ider or s}^u^pplier^ex^trem^{e h}^a^rds^hⁱ^p^{, 6-}^y^{ear repay}^m^en^{t plan}^s
^f^a^ils^{to m}^a^k^e^{a s}^c^h^e^du^{led pay}^m^en^t,^th^{e Secretary}^w^o^u^l^d^b^e^p^e^r^m^itted^.^I^f^th^{e p}^r^o^v^id^er^o^r
^m^a^y^im^m^e^diately^of^f^s^{et or recov}^e^{r th}^e^ou^ts^tan^dⁱⁿ^g^s^u^pplⁱ^e^{r h}^a^{d prev}ⁱ^o^u^s^repay^m^en^t^pl^an^s^,^t^h^os^e

CRS-17
^Provisⁱ^ons^C^{urrent L}^a^w^S^{. 1}^H^{.R. 1}
^bal^aⁿ^{ce. T}^h^{e Secretary}^w^o^u^l^{d be requ}^{ired to}^co^u^l^dⁿ^o^{t to}^b^e^coⁿ^s^id^er^edⁱⁿ^d^e^ter^mⁱⁿⁱⁿ^g
^dev^e^lop^s^t^an^dards^f^o^{r th}^{e recov}^e^ry^of^ha^r^d^shi^p^.
^ov^erpay^m^en^t^s^.
^tioⁿ^oⁿ^(h⁾⁽²⁾^T^h^{e S}^ecret^ary^w^o^u^l^{d be proh}ⁱ^bⁱ^t^e^{d f}^r^om^(f)(2)^Sⁱ^mⁱ^l^a^r^provⁱ^sⁱ^oⁿ^.^Wou^l^{d prov}ⁱ^d^{e f}^o^r
^ent^recou^pⁱⁿ^g^aⁿ^y^ov^erpay^m^en^ts^uⁿ^t^{il a}^redetermⁱⁿ^ation^by^{a Medicare}^con^t^{ractor in}
^recon^s^ideration^-^lev^e^{l appeal}ⁱ^s^deci^{ded (i}^f^on^e^w^a^s^th^{e ev}^en^{t th}^{at q}^u^alif^ie^dⁱⁿ^d^e^p^eⁿ^d^en^t
^requ^es^t^e^{d). In}^t^e^res^t^w^o^u^l^{d be pai}^d^t^o^t^h^{e prov}ⁱ^d^er^con^t^ractors^h^a^v^eⁿ^o^{t been}^es^tablis^h^e^d.
^if^th^e^appeal^is^s^u^cces^s^f^u^l^(begⁱⁿⁿⁱⁿ^g^f^r^om^th^{e tim}^e
^th^{e ov}^erpay^m^en^{t is}^recou^p^{ed) or th}^{at in}^teres^t^s^h^all
^{be paid to th}^{e Secretary}^if^th^{e appeal is}
^uⁿ^s^u^ccessf^u^l⁽^aⁿ^d^if^th^{e o}^v^er^p^a^y^m^en^t^isⁿ^o^t^p^a^id^to
^th^{e Secretary}⁾^.
^e^nt^audi^t^s^(h⁾⁽³⁾^I^f^p^o^s^t-^p^a^y^m^en^t^au^d^{its w}^e^r^e^coⁿ^d^u^c^ted^,^th^e^(f)(7)^Sim^ilar^p^r^o^v^isioⁿ^.^A^l^so^w^o^u^l^d^r^e^q^u^ir^e
ⁱ^{ki/CRS-RL31901}^Medi^{care con}^t^ract^{or w}^o^u^l^{d be requ}ⁱ^r^{ed t}^o^provⁱ^d^e^th^{e p}^r^o^v^id^er^o^r^su^p^p^lⁱ^e^r^w^ith^w^r^ittenⁿ^o^{tice o}^f^th^e^th^{e Med}ⁱ^{care con}^t^ractor^to^coⁿ^s^id^er^th^eⁱⁿ^f^o^rm^atⁱ^oⁿ^provⁱ^d^{ed by}^t^h^{e prov}ⁱ^d^{er or}
^g/wⁱⁿ^ten^t^to^coⁿ^d^u^c^{t th}^{e au}^d^{it. T}^h^{e co}ⁿ^t^r^acto^r^w^o^u^l^d^su^p^p^lier^.
^s^.or^f^u^rt^h^e^{r be}^requⁱ^r^{ed t}^o^gⁱ^v^e^t^h^{e prov}ⁱ^d^{er or s}^u^pplⁱ^e^r
^le^ak^{a f}^u^{ll an}^{d u}ⁿ^d^ers^t^an^{dable ex}^plan^ation^{of th}^e
^://wiki^fⁱⁿ^dⁱⁿ^g^s^o^f^th^{e au}^d^{it an}^d^p^e^r^m^it^th^{e d}^e^v^e^lo^p^m^en^{t o}^f^an^{appropriate corre}^c^tⁱ^v^{e action}^plan^{, in}^f^o^rm^th^e
^h^ttp^provⁱ^d^{er or s}^u^pplⁱ^e^r^of^appeal^ri^g^h^t^s^an^{d con}^s^en^t
^settlem^eⁿ^t^o^p^tioⁿ^s^{, an}^d^gⁱ^v^e^th^{e p}^r^o^v^id^er^o^r
^s^u^{pplier th}^{e opportu}ⁿⁱ^t^y^{to prov}^{ide addition}^a^l
ⁱⁿ^f^o^r^m^atioⁿ^to^th^{e co}ⁿ^t^r^acto^r^,^uⁿ^{less n}^o^{tice o}^r
^fⁱⁿ^dⁱⁿ^g^s^w^o^u^l^{d com}^p^romⁱ^s^e^an^y^la^w^en^f^o^rcem^en^t
^activ^ities.
^-^(h⁾⁽⁴⁾^T^h^{e Secretary}^w^o^u^l^{d be requ}^{ired to}^(f)(6)^S^a^m^e^provⁱ^sⁱ^oⁿ^.

^tioⁿ^o^f^co^d^e^s^estab^lish^{a p}^r^o^c^e^s^s^to^p^r^o^v^id^{e n}^o^{tice to}^cer^tain
^p^r^o^v^id^er^{s an}^d^su^p^p^lie^r^sⁱⁿ^{cases w}^h^er^{e b}^illin^g
^co^d^e^{s ar}^{e o}^v^er^-^u^tilized^b^y^m^e^m^b^er^{s o}^f^th^{at class in}
^cer^tain^ar^e^a^s^{, in}^coⁿ^s^u^ltatioⁿ^w^ith^o^r^g^aⁿⁱ^zatioⁿ^s
^th^{at repr}^e^s^eⁿ^{t th}^{e af}^f^{ected prov}^{ider or s}^u^pplier
^clas^s^.

CRS-18
^Provisⁱ^ons^C^{urrent L}^a^w^S^{. 1}^H^{.R. 1}
^t^andar^d^(h⁾⁽⁵⁾^T^h^{e Secretary}^w^o^ul^{d be requ}^{ired to}^(f)(8)^S^a^m^e^provⁱ^sⁱ^oⁿ^.
^t^hodol^{ogy f}^o^r^pr^obe^es^t^a^blⁱ^s^h^{a s}^t^an^{dard m}^e^t^h^odol^og^y^f^o^{r Medi}^care
^mp^lin^g^con^t^ractors^{to u}^s^{e in}^s^e^lectin^g^a^s^a^m^p^{le of}^claim^s
^f^o^r^r^e^vⁱ^ewⁱⁿ^{cases o}^f^abⁿ^o^r^m^{al b}^illin^g^p^a^tterⁿ^s.
ⁿ^s^en^{t settlemen}^t^(h⁾⁽⁶⁾^W^o^u^l^d^perm^it^th^e^Secretary^{to u}^s^{e a con}^s^en^t^(f)(5)^Su^b^s^tan^tially^sim^ilar^p^r^o^v^isioⁿ⁽^mⁱⁿ^o^r
^fo^rms^settlem^eⁿ^t^p^r^o^{cess to}^{settle p}^r^o^j^ected^o^v^er^p^a^y^m^en^ts^di^f^f^e^ren^ces^).
^uⁿ^d^er^cer^tain^sp^ecifⁱ^ed^coⁿ^d^itioⁿ^s^.
^r^apol^atⁱ^oⁿ^N^o^provⁱ^sⁱ^oⁿ^.^(f)(3)^T^h^{e u}^s^{e of}^ex^trapolation^w^oul^d^b^e
^lim^ite^d^uⁿ^l^{ess th}^er^{e w}^a^{s a h}ⁱ^g^h^lev^e^{l o}^f
^pay^m^en^t^{error or docu}^m^en^t^e^{d edu}^catⁱ^o^nal
ⁱⁿ^ter^v^en^tioⁿ^h^a^d^f^a^iled^to^co^r^r^{ect th}^{e p}^a^y^m^en^t
^error.
ⁱ^{ki/CRS-RL31901}^o^c^e^{ss fo}^{r c}^o^rre^c^tioⁿ^No^ex^p^{licit statu}^t^o^r^yⁱⁿ^str^u^ctioⁿ^.^A^d^mⁱⁿⁱ^str^a^tiv^ely^,^S^ecti^oⁿ^543.^T^h^{e Secretary}^w^o^u^l^{d be}^requ^{ired to}^S^ecti^oⁿ^937.^S^a^m^e^p^r^o^v^isioⁿ^r^e^latin^g^to
^g/wⁱ^nor^er^r^o^r^s^and^th^{e Medicar}^e^con^t^ractors^s^eⁿ^d^{a claim}^s^denⁱ^al^es^tablis^h^{a proces}^s^s^o^prov^iders^an^{d s}^u^ppliers^can^co^r^r^ectin^g^mⁱⁿ^o^r^er^r^o^r^s^{. Co}ⁿ^t^ain^s^ad^d^itioⁿ^a^l
^s^.orⁱ^s^sⁱ^ons^w^h^en^{a claim}^h^a^{s b}^een^su^b^m^itted^lackⁱⁿ^g^r^e^q^u^ir^ed^{correct m}ⁱⁿ^o^{r errors}ⁱⁿ^claim^s^th^{at h}^a^v^e^been^prov^is^ion^th^{at w}^o^u^l^{d requ}^{ire th}^{e Secretary}^to
^le^akⁱⁿ^form^ation^.^A^m^en^dm^en^ts^{to cos}^t^reports^{are n}^o^t^su^b^m^itted^f^o^r^p^a^y^m^en^t.^p^e^r^m^{it h}^o^sp^{itals to}^c^o^r^r^{ect w}^a^g^e^d^a^{ta er}^r^o^r^s
^allo^w^e^d^oⁿ^{ce a co}^{st r}^e^p^o^r^{t is settled}^.^th^{at af}^f^ect^g^e^og^raph^{ic reclas}^sⁱ^fⁱ^cation^ev^en^if
^://wiki^th^e^cos^t^{report h}^a^s^been^s^e^ttled.^For^FY2004
^h^ttp^aloⁿ^{e, th}^{e r}^e^s^u^b^m^{ittal o}^f^th^{e ap}^p^licatioⁿ^f^o^r^g^e^og^raphⁱ^c^recl^as^sⁱ^fⁱ^catⁱ^oⁿ^w^o^u^l^{d be}
^p^e^r^m^itted^.
^th^o^r^{ity to}^wa^ive^T^h^{e Secretary}^h^a^s^th^e^au^th^ority^{to w}^a^iv^{e ex}^clu^s^ion^S^ecti^oⁿ^544.^T^h^{e Secr}^etar^y^w^o^u^l^d^b^e^p^e^r^m^itted^to^S^ecti^oⁿ^949.^S^a^m^e^provⁱ^sⁱ^oⁿ^.

^ogr^{am exclus}^ion^f^r^om^partⁱ^cⁱ^p^atⁱ^onⁱⁿ^an^y^f^e^deral^h^eal^t^h^prog^ram^w^a^iv^{e a prog}^ram^ex^clu^s^ion^{at th}^{e requ}^e^s^t^of^an
^w^h^en^th^{e prov}^iderⁱ^s^th^{e s}^o^{le s}^o^u^r^{ce of}^{care in}^a^admⁱⁿⁱ^s^t^{rator of}^{a f}^e^{deral h}^ealth^{care pr}^o^g^ram
^com^m^uⁿ^ity^{, at th}^{e requ}^es^{t of}^{a s}^t^ate.^(w^hⁱ^chⁱⁿ^clu^d^es^s^t^{ate h}^ealth^{care prog}^ram^s^).

CRS-19
tle F. Other Improvements
^Provisⁱ^ons^C^{urrent L}^a^w^S^{. 1}^H^{.R. 1}
^usⁱ^{on of}^addi^tⁱ^onal^A^l^t^h^o^{ugh t}^h^e^st^a^t^ut^e^r^e^q^uⁱ^r^e^s^t^h^a^t^b^e^ne^fi^cⁱ^a^rⁱ^e^s^S^ecti^oⁿ^551.^B^eⁿ^e^fⁱ^ciaryⁿ^o^tices^f^o^{r th}^os^e^S^ecti^oⁿ^925.^Sim^ilar^p^r^o^vⁱ^s^ioⁿ^.^W^o^u^l^d
^rma^tioⁿⁱⁿⁿ^o^tices^receiv^e^{a s}^t^a^t^e^m^eⁿ^{t lis}^tin^g^th^{e item}^s^an^{d s}^e^rv^ices^b^eⁿ^e^fⁱ^ciar^{ies in}^{SNFs a}ⁿ^d^h^o^sp^{ital w}^o^u^l^d^b^e^r^e^q^u^ir^{e in}^f^o^r^m^atioⁿ^f^o^r^b^eⁿ^e^fⁱ^ciar^iesⁱⁿ^{a SNF}
ⁱ^cⁱ^a^rⁱ^es^about^f^o^{r w}^h^ich^pay^m^en^t^ha^s^been^m^a^{de, th}^{ere is}ⁿ^o^r^e^q^u^ir^ed^toⁱⁿ^clu^d^{e in}^f^o^r^m^atioⁿ^ab^o^u^{t th}^eⁿ^u^m^b^e^r^sta^y^oⁿ^ly^.
ⁿ^u^rsin^g^fa^cility^ex^p^{licit statu}^t^o^r^yⁱⁿ^str^u^ctioⁿ^th^{at r}^e^q^u^ir^{es th}^{e n}^o^tice^o^f^d^a^y^s^o^f^c^o^ve^r^a^ge^r^e^m^aⁱⁿⁱ^{ng und}^e^r^t^h^e^SN^F
^N^F⁾^{and hos}^pi^t^a^l^toⁱⁿ^clu^d^{e in}^f^o^r^m^atioⁿ^ab^o^u^{t th}^{e n}^u^m^b^e^r^o^f^d^a^y^s^o^f^b^eⁿ^e^f^{it an}^d^th^{e sp}^{ell o}^f^illn^{ess in}^v^o^lv^ed^.
ⁿ^e^fits^co^v^e^r^a^g^e^r^e^m^aⁱⁿⁱⁿ^gⁱⁿ^eith^er^th^{e h}^o^sp^{ital o}^r^SNF
^b^eⁿ^e^f^it.
^o^r^m^atⁱ^{on on}^T^h^e^ho^spⁱ^t^a^l^dⁱ^sc^ha^r^g^e^p^l^aⁿⁿⁱ^{ng p}^r^o^c^e^s^s^r^e^q^uⁱ^r^e^s^S^ecti^oⁿ^552.^T^h^e^Secretary^w^o^u^l^d^{be requ}^{ired to}^S^ecti^oⁿ^926.^S^a^m^e^provⁱ^sⁱ^oⁿ^.
ⁱ^ca^re-^certified^S^N^F^ev^alu^a^tion^o^f^{a patien}^t^’^s^lik^elyⁿ^{eed f}^o^{r pos}^t-^m^a^k^eⁱⁿ^f^o^r^m^atioⁿ^p^u^b^lⁱ^cly^av^ailab^l^{e r}^e^g^a^r^dⁱⁿ^g
^pi^t^a^l^di^s^c^har^ge^h^o^s^p^{ital s}^e^rv^icesⁱⁿ^clu^dⁱⁿ^g^h^o^s^p^{ice an}^{d h}^o^m^e^care.^w^h^eth^e^r^{SNFs w}^e^r^e^p^a^r^ticip^atin^gⁱⁿ^th^{e Med}ⁱ^car^e
^prog^r^a^m^.^H^o^s^pⁱ^t^a^l^di^s^c^h^a^rg^{e pl}^anⁿⁱⁿ^g^w^o^u^l^{d be}
^requ^{ired to in}^clu^d^{e ev}^alu^a^tin^g^a^patien^t^’^sⁿ^{eed f}^o^r
ⁱ^{ki/CRS-RL31901}^{SNF care.}
^g/w^ysiciaⁿ^eva^lu^a^tioⁿ^In^{itial E&}^{M g}^uⁱ^delin^es^w^e^{re is}^s^u^{ed in}^{1995 w}^ith^S^ecti^oⁿ^553.^T^h^{e Secretary}^w^o^u^l^{d be requ}^{ired to}^S^ecti^oⁿ^941.^W^o^ul^d^b^a^{r th}^{e Secretary}^f^r^om
^s^.or^anagem^e^nt^revⁱ^sⁱ^on^sⁱ^s^s^u^{ed i}ⁿ^{1997 an}^d^b^o^t^{h rem}^aⁱⁿⁱⁿ^f^o^rce^eⁿ^sur^e^,^b^e^fo^r^e^m^a^ki^{ng c}^h^a^nge^{s i}ⁿ^d^o^c^um^eⁿ^t^a^tⁱ^oⁿ^im^p^l^em^en^tin^gⁿ^e^w^{E an}^d^{M d}^o^c^u^m^en^tatioⁿ
^le^ak^&^M⁾^docum^ent^a^tⁱ^oⁿ^t^oday^.^A^pproxⁱ^m^at^el^y^40%^of^Medi^{care pay}^m^en^t^s^g^uⁱ^delin^es^f^o^r,^or^clin^{ical ex}^am^ples^of^{, or codes}^to^g^uⁱ^delin^es^uⁿ^l^es^s^th^{e Secretary}^f^o^llo^w^e^{d th}^e
^delⁱⁿ^es^f^o^r^p^h^y^s^ician^ser^v^ice^s^ar^{e f}^o^r^ser^v^{ices w}^h^ich^ar^e^r^e^p^o^r^{t E an}^d^{M p}^h^y^s^ician^ser^v^{ices, th}^{at th}^e^cr^iterⁱ^{a laid}^o^u^{t in}^th^{e p}^r^o^v^isioⁿ^.
^://wiki^clas^sⁱ^fⁱ^{ed as}^ev^alu^a^tion^an^{d m}^aⁿ^a^g^e^m^eⁿ^t^s^e^rv^ices^p^r^o^c^e^{ss use}^dⁱⁿ^d^e^ve^l^o^pⁱ^{ng t}^h^e^gui^d^e^lⁱⁿ^e^s^,
^h^ttp^{(i.e., ph}^y^s^ician^vⁱ^s^its^{). T}^h^{e Secretary}^anⁿ^o^uⁿ^ced^ex^am^pl^es^{, or codes}^w^a^s^wⁱ^del^y^con^s^u^l^t^a^tⁱ^v^e
^t^h^a^t^H^H^S^w^a^s^s^t^oppiⁿ^g^w^o^rk^on^t^h^{e cu}^rren^t^re^-^am^on^g^ph^y^sⁱ^cⁱ^aⁿ^s^{, ref}^l^ects^{a broad con}^s^en^s^u^s
^d^r^a^f^t^of^{E an}^{d M codes}ⁱⁿ^{order t}^o^reas^s^e^s^s^t^h^e^am^oⁿ^g^sp^{ecialties, a}ⁿ^d^w^o^u^l^d^allo^w^v^e^rⁱ^fⁱ^catioⁿ
^en^{tire ef}^f^o^rt.^of^report^e^{d an}^{d f}^u^rnⁱ^s^h^e^{d s}^e^rvⁱ^ces^.
^{ovement in}⁽^a⁾^No^ex^p^{licit statu}^t^o^r^y^p^r^o^v^isioⁿ^oⁿ^th^{e Co}^uⁿ^c^il.^S^ecti^oⁿ^554.^W^o^ul^{d requ}^{ire th}^{e Secretary}^to^S^ecti^oⁿ^942.^Sam^e^p^r^o^v^isioⁿ^oⁿ^th^e^Co^uⁿ^c^il.
^sⁱ^ght^of^t^echnol^ogy^Un^d^e^r^ad^mⁱⁿⁱ^str^a^tiv^{e au}^th^o^r^{ities, CMS}^anⁿ^o^uⁿ^ced^e^s^t^a^b^lⁱ^s^{h a}^Co^uncⁱ^l^fo^r^T^e^c^hno^l^o^gy^aⁿ^d^A^l^so^w^o^u^l^d^r^e^q^u^ir^{e th}^{e S}^e^c^r^e^t^ar^y^to^estab^lish
^ageⁱⁿ^March^{2003 t}^h^{e es}^t^a^blⁱ^s^h^m^en^t^of^{a t}^echⁿ^o^l^o^g^y^Inⁿ^o^v^a^tⁱ^o^{n com}^pos^{ed of}^s^eⁿⁱ^{or C}^M^S^s^t^af^f^an^d^procedu^r^es^f^o^{r determ}ⁱⁿⁱⁿ^g^th^{e bas}ⁱ^s^{for an}^d
^couⁿ^cⁱ^l^c^h^a^r^ge^d^wⁱ^t^hⁱ^m^provⁱⁿ^g^Medi^care^clin^ician^s^to^co^o^r^dⁱⁿ^a^{te co}^v^e^r^a^g^e^{, co}^dⁱⁿ^g^,^an^d^am^ouⁿ^t^of^pay^m^eⁿ^{t f}^o^{r a n}^e^w^clin^ical
^cov^e^rag^e^{, co}^dⁱⁿ^g^an^{d pay}^m^en^{t f}^o^{r em}^ergⁱⁿ^g^pay^m^en^t^proces^s^e^s^uⁿ^d^er^Tⁱ^t^l^e^{XVIII an}^{d t}^h^e^dⁱ^agⁿ^o^{stic lab}^o^r^at^o^r^y^{test th}^{at h}^a^{s b}^een
^t^e^c^hno^l^o^gi^e^s^.^Co^uncⁱ^l^m^e^m^b^e^r^shi^pⁱⁿ^c^l^ud^e^s^seⁿⁱ^o^r^e^x^c^h^a^nge^o^fⁱⁿ^fo^r^m^a^tⁱ^o^{n o}ⁿ^ne^w^t^e^c^hno^l^o^gi^e^s^assigⁿ^e^d^{a n}^e^w⁽^o^r^su^b^s^tan^tially^r^e^vⁱ^sed⁾
^C^M^{S s}^t^af^f^.^T^h^{e Health}^C^a^{re P}^r^ocedu^r^{e C}^odin^g^b^e^tw^een^{CMS an}^d^o^t^h^e^r^en^{tities th}^{at m}^a^k^e^sim^ilar^Health^C^a^{re P}^r^ocedu^r^{e C}^odin^g^Sy^s^t^em
^Sy^s^t^em⁽^H^C^P^C^S^{) is}^th^{e procedu}^r^{e codin}^g^s^y^s^t^em^d^e^cⁱ^sioⁿ^s.^(H^C^P^C^S⁾^code^af^t^e^{r Jan}^u^a^ry^{1, 2005.}^Wou^l^d
^u^s^{ed f}^o^{r P}^a^{rt B}^item^s^an^{d s}^e^rv^ices^{. No s}^t^atu^t^ory^requ^ire^{a GA}^{O s}^t^u^d^y^an^aly^zⁱⁿ^g^w^h^ich^ex^tern^al
^prov^is^ion^reg^a^rdin^g^th^e^GA^{O s}^t^u^d^y^.^T^h^{e Secretary}^{data cou}^l^d^be^{collected in}^{a s}^h^{orter tim}^{e f}^r^am^e
ⁱ^s^r^e^q^u^ir^ed^to^r^e^ly^oⁿ^r^eco^m^m^eⁿ^d^atioⁿ^s^o^f^th^e^th^an^th^{at cu}^r^r^en^tly^u^s^edⁱⁿ^co^m^p^u^tin^gⁱⁿ^p^a^tien^t
^Natioⁿ^a^{l Co}^m^m^{ittee o}ⁿ^{Vital an}^d^Health^Statistics^h^o^sp^{ital p}^a^y^m^en^{ts. W}^o^u^l^d^p^e^r^m^{it th}^{e Secr}^etar^y
^(N^C^V^H^S^{) i}ⁿ^adoptⁱⁿ^g^s^t^an^dards^uⁿ^d^{er H}^I^PA^A^.^t^o^adopt^t^h^{e I}ⁿ^t^e^rn^atⁱ^oⁿ^a^l^C^l^as^sⁱ^fⁱ^catⁱ^oⁿ^of

CRS-20
^Provisⁱ^ons^C^{urrent L}^a^w^S^{. 1}^H^{.R. 1}
^T^h^{e cu}^rren^t^s^t^an^{dard f}^o^{r diag}ⁿ^o^sⁱ^s^c^odes^is^th^e^th^Dis^eas^es^{, 10}^th^R^e^vⁱ^sⁱ^on^{, Procedu}^r^{e C}^odiⁿ^g
^Iⁿ^terⁿ^atioⁿ^a^{l Classif}ⁱ^catioⁿ^o^f^{Diseases, 9}^S^y^s^t^em^(IC^D^-^10-^PC^S⁾^an^{d t}^h^{e IC}^D^-^10-
^Re^vi^si^oⁿ^,^Clⁱⁿⁱ^c^a^l^M^o^dⁱ^fi^c^a^tⁱ^oⁿ^(IC^D-^9-^C^M^).^I^C^D^-^C^lin^{ical Modif}ⁱ^cation^(C^{M) w}^ith^ou^{t receiv}ⁱⁿ^g
⁹^-^{CM is th}^{e b}^a^{sis o}^f^th^{e Med}ⁱ^car^{e in}^p^a^tien^t^a^recom^m^eⁿ^d^{ation fr}^o^m^th^e^Nation^a^l
^h^o^sp^{ital P}^P^S^p^a^y^m^en^{t sy}^stem^.)^T^h^{e NCVHS h}^a^s^Co^m^m^{ittee o}ⁿ^{Vital an}^d^Health^Statistⁱ^cs
ⁿ^o^{t m}^a^{de a recom}^m^eⁿ^d^ation^{to th}^{e Secretary}^abou^t^th^(NC^VHS^).
^IC^D^-^10-^PC^S^(t^h^e¹⁰^revⁱ^sⁱ^on^{, proc}^edu^r^{e codi}ⁿ^g
^s^y^s^t^em^{) or IC}^D^-^10-^C^M^.
^nt^al^cl^ai^m^s^T^h^{e s}^t^atu^t^{e doe}^s^no^t^a^u^t^h^{orize den}^t^{al ben}^e^f^itsⁱⁿ^S^ecti^oⁿ^555.^Startin^g^{60 day}^s^af^{ter en}^actm^eⁿ^t^,^a^S^ecti^oⁿ^950.^S^a^m^e^provⁱ^sⁱ^oⁿ^.
^Medi^{care. A}^pparen^t^l^y^{, s}^o^m^eⁱⁿ^s^u^rers^m^a^y^requⁱ^r^e^g^r^ou^{p h}^eal^t^h^pl^an^provⁱ^dⁱⁿ^g^s^uppl^em^en^t^a^l^or
^{a claim}^denⁱ^{al f}^r^om^Medicare^bef^o^re^acceptin^g^th^e^s^econ^d^ary^cov^e^rag^e^{to Medicare ben}^e^fⁱ^ciaries
^claim^f^o^r^pay^m^en^t^revⁱ^ew^,^ev^en^if^th^{e s}^e^rv^{ice is}ⁿ^o^t^w^o^u^l^dⁿ^o^{t b}^e^ab^{le t}^o^r^e^q^u^ir^{e d}^eⁿ^{tists to}^o^b^t^ain^a
^cov^e^{red by}^Medicare.^claim^denⁱ^{al f}^r^om^{Medicare f}^o^rⁿ^oⁿ^c^ov^ered^den^t^al
ⁱ^{ki/CRS-RL31901}^s^e^rv^ices^{prior to pay}ⁱⁿ^g^th^{e claim}^.^e^di^car^e^s^econdar^y^In^certainⁱⁿ^s^t^an^ces^w^h^en^{a ben}^e^fⁱ^ciary^h^a^s^o^t^her^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ^943.^T^h^e^Secretary^w^o^u^l^{d n}^o^{t be}^able
^g/wⁱⁿ^s^u^ran^{ce cov}^e^rag^e^{, Medicare becom}^e^s^th^e^to^r^e^q^u^ir^e^th^{at a h}^o^sp^{ital o}^b^t^ainⁱⁿ^f^o^r^m^atioⁿ^oⁿ
^s^.or^secoⁿ^d^ar^yⁱⁿ^su^r^aⁿ^ce.^Aⁿ^en^tity^f^u^rⁿ^ishⁱⁿ^g^{a P}^a^r^t^B^ot^h^e^{r i}ⁿ^s^u^ran^{ce co}^verag^e^f^o^{r ref}^e^ren^c^e
^le^ak^ser^v^{ice is r}^e^q^u^ir^ed^to^o^b^t^ainⁱⁿ^f^o^r^m^atioⁿ^f^r^o^m^th^e^laboratory^s^e^rv^ices^{, if}^th^{e Secr}^etary^doesⁿ^o^t
^://wiki^ben^e^fⁱ^ciary^on^w^h^eth^e^{r oth}^e^{r in}^s^u^ran^{ce cov}^e^rag^e^is^av^ailable.^im^pos^{e s}^u^ch^r^e^q^uⁱ^r^em^en^tsⁱⁿ^th^{e cas}^{e of}^ser^v^{ices f}^u^rⁿ^ish^e^d^b^yⁱⁿ^d^e^p^eⁿ^d^en^t
^h^ttp^l^a^borat^ori^e^s^.
^{gency Medical}^Medⁱ^car^{e p}^a^r^ticip^atin^g^h^o^sp^{itals th}^{at o}^p^e^r^{ate an}^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ^944.^{For EMT}^A^L^A^-^r^equⁱ^red^s^e^rv^ices
^eat^m^ent^{and Act}ⁱ^v^e^em^erg^eⁿ^c^y^room^{are requ}^{ired to prov}^{ide n}^eces^s^a^ry^prov^id^e^d^t^o^{a Medicare ben}^e^fⁱ^ciary^,
^Act⁽^E^M^T^AL^A)^s^c^reenⁱ^{ng an}^{d s}^t^abilization^s^e^rv^ices^{to an}^y^patien^t^d^e^ter^mⁱⁿ^atioⁿ^s^ab^o^u^{t m}^e^dⁱ^{cal n}^ecessity^w^o^u^l^d
^ovements^w^h^{o com}^e^s^to^an^em^erg^eⁿ^c^y^departm^eⁿ^t^requ^es^tin^g^{be requ}ⁱ^r^{ed t}^o^{be m}^a^{de on}^t^h^{e bas}ⁱ^s^of^t^h^e
^ex^amⁱⁿ^atioⁿ^o^r^tr^eatm^eⁿ^t^f^o^r^{a m}^e^dⁱ^{cal co}ⁿ^d^itioⁿ^,ⁱⁿ^f^o^r^m^atioⁿ^av^ailab^l^{e to}^th^e^tr^eatin^g^p^h^y^s^ician
ⁱⁿ^order^{to determ}ⁱⁿ^{e w}^h^eth^e^{r an}^em^erg^eⁿ^c^y^o^r^p^r^actitioⁿ^e^r^{at th}^{e tim}^{e th}^{e item}^o^r^ser^vⁱ^c^e
^m^e^dⁱ^c^a^{l situ}^atioⁿ^ex^{ists. Ho}^sp^{itals f}^o^uⁿ^dⁱⁿ^w^a^s^{ordered or f}^u^rnⁱ^s^h^e^{d an}^{d n}^o^t^on^t^h^e
^vⁱ^olation^of^EMT^A^L^A^m^a^y^f^ace^cⁱ^v^{il m}^oⁿ^e^y^patⁱ^eⁿ^t^’^s^prin^{cipal diag}ⁿ^o^sⁱ^s^.^T^h^{e Secretary}
^p^eⁿ^a^{lties an}^d^ter^mⁱⁿ^atioⁿ^o^f^th^eir^p^r^o^v^id^er^w^o^u^l^{d be requ}^{ired to es}^tablis^h^a^procedu^r^{e to}
^ag^reem^en^t.ⁿ^o^tif^y^h^o^sp^{itals an}^d^p^h^y^s^ician^s^w^h^en^an
^EMT^A^L^Aⁱⁿ^v^e^stig^atioⁿ^{is clo}^s^ed^.

CRS-21
^Provisⁱ^ons^C^{urrent L}^a^w^S^{. 1}^H^{.R. 1}
^Ex^cep^tⁱⁿ^th^{e cas}^{e w}^h^{ere a delay}^w^o^u^l^d
^j^e^opardi^{ze t}^h^{e h}^eal^t^h^an^{d s}^a^f^e^t^y^ofⁱⁿ^di^vⁱ^du^al^s^,
^th^{e Secretary}^w^o^u^l^{d be r}^e^qu^{ired to requ}^es^{t a}
^P^R^O^r^e^vi^e^w^b^e^fo^r^e^m^a^ki^{ng a}^c^o^m^p^lⁱ^aⁿ^c^e
^d^e^ter^mⁱⁿ^a^t^ioⁿ^th^{at w}^o^u^l^d^ter^mⁱⁿ^{ate a}
^hos^pital’^s^{Medicare participation}^becau^s^e^o^f
^EMT^A^L^A^vⁱ^ol^atⁱ^oⁿ^.^T^h^{e peri}^{od of}^{5 bu}^sⁱⁿ^e^s^s
^day^s^w^o^u^l^d^appl^y^t^o^s^u^ch^{a PR}^O^revⁱ^ew^.^T^h^e
^Secretary^w^o^u^l^{d be requ}^{ired to prov}^ide^a^copy
^o^f^t^h^{e r}^e^p^o^r^{t to}^th^{e h}^o^sp^{ital o}^r^p^h^y^s^ician^,
^coⁿ^sⁱ^s^t^eⁿ^t^w^ith^ex^istin^g^coⁿ^f^id^en^tiality
^r^e^q^u^ir^em^en^{ts. T}^h^{is p}^r^o^v^isioⁿ^w^o^u^l^d^ap^p^l^y^to
^ter^mⁱⁿ^atioⁿ^sⁱⁿ^itiated^oⁿ^o^r^af^ter^en^actm^eⁿ^t^.
ⁱ^{ki/CRS-RL31901}^T^h^{e requ}ⁱ^r^em^en^t^f^o^{r a h}^o^s^pⁱ^t^a^l^t^o^condu^ct^an^{appropriate m}^e^{dical s}^c^reenⁱⁿ^g^ex^amⁱⁿ^ation^f^o^r
^g/w^{a patien}^t^pres^eⁿ^tin^gⁱⁿ^th^{e em}^erg^eⁿ^c^y
^s^.or^departm^eⁿ^t^w^o^u^l^{d n}^o^{t in}^clu^d^{e cas}^es^w^h^{ere an}
^le^akⁱⁿ^divⁱ^du^{al com}^e^s^to^an^em^erg^eⁿ^c^y^departm^eⁿ^t
^an^{d t}^h^{e i}ⁿ^di^vⁱ^du^al^{(or ano}^t^h^e^{r pers}^on^on^t^h^e
^://wikiⁱⁿ^di^vⁱ^du^al^’^s^beh^a^l^f^{) does}ⁿ^o^t^s^p^eci^fⁱ^cal^l^y
^h^ttp^requ^es^{t an}^e^x^a^mⁱⁿ^ation^{or treatm}^eⁿ^t^f^o^{r an}
^em^er^g^eⁿ^c^y^m^e^dⁱ^{cal co}ⁿ^d^itioⁿ^.
^TA^LA^techⁿⁱ^ca^l^No^ex^p^{licit statu}^t^o^r^yⁱⁿ^str^u^ctioⁿ^.^No^p^r^o^v^isioⁿ^.^S^ecti^oⁿ^945.^T^h^{e Secretary}^w^o^u^l^{d be}^requ^ired
^s^or^{y gr}^oup^{to es}^tablis^h^{a te}^chⁿⁱ^{cal adv}ⁱ^s^o^ry^g^r^ou^p
^com^p^ri^s^e^{d of}^t^h^{e C}^M^S^A^d^mⁱⁿⁱ^s^t^rat^o^r^,^t^h^e
^Iⁿ^sp^ecto^r^Gen^e^r^a^{l o}^f^HHS,^h^o^sp^{ital, p}^h^y^s^ician
^an^{d patien}^t^r^e^pres^en^tativ^es^{, C}^M^{S s}^t^af^f
ⁱⁿ^v^e^s^tig^atin^g^EMT^A^L^A^cas^es^an^d^{a s}^t^ate
^s^u^rv^ey^of^fⁱ^ce^r^e^pres^en^tativ^{e to rev}ⁱ^ew^is^s^u^es
^r^e^lated^to^EMT^A^L^A^.

CRS-22
^Provisⁱ^ons^C^{urrent L}^a^w^S^{. 1}^H^{.R. 1}
^re^h^o^s^pⁱ^c^e^se^rv^ic^e^s^A^h^o^sp^{ice m}^u^st^en^su^r^e^th^{at su}^b^s^tan^tially^all^its^co^r^e^Se^c^tⁱ^oⁿ^406.^A^h^o^sp^{ice w}^o^u^l^d^b^e^p^e^r^m^itted^to^{Section 946}^{. Sam}^e^prov^is^ion^.
^s^e^rv^ices^{are rou}^tin^ely^prov^{ided directly}^by^h^o^s^p^ice^eⁿ^t^e^rⁱⁿ^t^o^a^r^r^a^nge^m^e^nt^{s w}ⁱ^t^h^aⁿ^o^t^he^r^ho^spⁱ^c^e
^e^m^p^l^o^y^e^e^s⁽ⁱ^nc^l^u^dⁱ^{ng vo}^l^unt^e^e^r^s)^o^r^,^d^u^rⁱ^{ng p}^e^a^k^prog^ram^{to p}^r^ov^{ide core s}^e^rv^{ice in}^ex^traordin^ary
^patien^t^loads^or^uⁿ^d^er^ex^traordin^ary^circu^m^s^t^an^ces^,^circu^m^s^t^an^ces^{, s}^u^ch^as^uⁿ^aⁿ^{ticipated h}ⁱ^g^h^patien^t
^by^con^t^{ract s}^t^af^f^.^C^e^rtain^ho^s^pⁱ^c^esⁱⁿⁿ^oⁿ^-^l^o^ad^{s, staf}^fⁱⁿ^g^sh^o^r^tag^e^{s d}^u^{e to}^illn^{ess o}^r
^u^r^banⁱ^{zed areas}^can^receiv^e^w^a^iv^ers^{to th}^is^tem^porary^trav^{el by}^a^patien^t^ou^ts^{ide th}^{e h}^o^s^p^ice’^s
^requ^irem^en^t.^ser^v^{ice ar}^ea^;^an^d^b^{ill an}^d^b^e^p^a^id^f^o^r^th^{e h}^o^sp^ice
^{care prov}^{ided u}ⁿ^d^{er th}^es^{e arran}^g^e^m^eⁿ^t^s^.
^H^A^bl^oodbor^ne^S^e^c^tⁱ^oⁿ^{1866 e}^s^t^a^blⁱ^s^h^e^s^c^e^r^t^aⁱⁿ^c^oⁿ^d^ition^s^of^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ^947.^A^s^o^f^Ju^l^y^1,^2004,^pu^blⁱ^c
^hogens^s^t^andar^ds^p^a^r^ticip^atioⁿ^t^h^a^t^h^o^s^p^{itals m}^u^{st m}^{eet in}^o^r^d^e^r^to^h^o^sp^{itals th}^{at ar}^{e n}^o^{t o}^t^h^e^r^w^{ise su}^b^j^{ect to}^th^e
^{participate in}^Medicare.^O^ccu^patⁱ^oⁿ^a^l^S^a^f^e^t^y^an^{d H}^eal^t^h^A^c^t^of¹⁹⁷⁰
^w^o^u^l^d^b^e^r^e^q^uⁱ^r^e^d^to^co^m^p^ly^w^ith^th^e
^Bl^oodborn^e^Pat^h^og^en^s^s^t^an^{dard u}ⁿ^d^{er S}^ectⁱ^oⁿ
ⁱ^{ki/CRS-RL31901}^1910.1030^of^T^{itle 29 of}^th^e^C^{ode of}^Feder^a^l^Regul^atⁱ^ons^{. A}^h^o^sp^{ital th}^{at f}^a^{ils to}^co^m^p^ly
^g/w^w^ith^th^{e r}^e^q^u^ir^em^en^{t w}^o^u^l^d^b^e^su^b^j^{ect to}^a
^s^.or^cⁱ^vi^l^m^o^ne^t^a^r^y^p^e^na^l^t^y^,^b^u^t^w^o^ul^d^no^t^b^e
^le^ak^ter^mⁱⁿ^ated^f^r^o^m^p^a^r^ticip^atin^gⁱⁿ^Medⁱ^car^e.
^://wiki^e^{lated technical}^endm^ent^s^and^BIP^A^S^ectⁱ^oⁿ^{522 con}^t^aiⁿ^e^{d s}^e^v^e^ral^t^echⁿⁱ^cal^errors^.^N^o^provⁱ^sⁱ^oⁿ^.^S^ecti^oⁿ^948.^T^echⁿⁱ^{cal correction}^s^w^o^u^l^{d be}^m^a^{de t}^o^BIPA^S^ectⁱ^oⁿ^522.
^h^ttp^r^ections
ⁱ^ons^to^Un^d^e^r^cer^tain^cir^c^u^m^stan^{ces, a p}^e^r^s^oⁿ^o^r^en^tity^S^ecti^oⁿ^434.^En^tⁱ^tⁱ^es^{, as}^defⁱⁿ^e^{d by}^t^h^e^S^ecti^oⁿ^952.^S^a^m^e^provⁱ^sⁱ^oⁿ^.

^sⁱ^gnm^ent^o^t^h^e^r^th^an^th^{e in}^dⁱ^vⁱ^d^u^{al p}^r^o^v^idⁱⁿ^g^th^{e ser}^v^{ice m}^a^y^Secretary^,^cou^l^{d receiv}^e^{Medicare pay}^m^en^ts^f^o^r
^ovi^sⁱ^ons^receiv^e^{Medicare pay}^m^en^ts^.^s^e^rvⁱ^ces^provⁱ^d^{ed by}^{a ph}^y^sⁱ^cⁱ^aⁿ^{or ot}^h^e^{r pers}^on
^if^th^{e s}^e^rvⁱ^c^{e w}^a^s^prov^{ided u}ⁿ^d^{er a con}^t^ractu^a^l
^a^r^r^a^nge^m^e^nt^aⁿ^dⁱ^f^t^h^e^a^r^r^a^nge^m^e^ntⁱⁿ^c^l^ud^e^s^j^oⁱⁿ^t
^an^d^“^s^ev^er^{al liab}^ility^{” (}^liab^ility^f^o^r^sev^e^r^a^{l p}^a^r^ties)
^f^o^r^o^v^er^p^a^y^m^en^{t an}^d^th^{e en}^tities’^m^{eet p}^r^o^g^r^a^m
ⁱⁿ^teg^r^ity^sp^ecifⁱ^catioⁿ^s^d^e^ter^mⁱⁿ^ed^b^y^th^e
^Secretary^.