
From the U.S. Code Online via GPO Access
[wais.access.gpo.gov]
[Laws in effect as of January 23, 2000]
[Document not affected by Public Laws enacted between
  January 23, 2000 and December 4, 2001]
[CITE: 42USC1395h]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
        SUBCHAPTER XVIII--HEALTH INSURANCE FOR AGED AND DISABLED
 
        Part A--Hospital Insurance Benefits for Aged and Disabled
 
Sec. 1395h. Use of public or private agencies or organizations 
        to facilitate payment to providers of services
        

(a) Authorization for agreement by Secretary for implementation; scope 
        of agreement

    If any group or association of providers of services wishes to have 
payments under this part to such providers made through a national, 
State, or other public or private agency or organization and nominates 
such agency or organization for this purpose, the Secretary is 
authorized to enter into an agreement with such agency or organization 
providing for the determination by such agency or organization (subject 
to the provisions of section 1395oo of this title and to such review by 
the Secretary as may be provided for by the agreement) of the amount of 
the payments required pursuant to this part to be made to such providers 
(and to providers assigned to such agency or organization under 
subsection (e) of this section), and for the making of such payments by 
such agency or organization to such providers (and to providers assigned 
to such agency or organization under subsection (e) of this section). 
Such agreement may also include provision for the agency or organization 
to do all or any part of the following: (1) to provide consultative 
services to institutions or agencies to enable them to establish and 
maintain fiscal records necessary for purposes of this part and 
otherwise to qualify as hospitals, extended care facilities, or home 
health agencies, and (2) with respect to the providers of services which 
are to receive payments through it (A) to serve as a center for, and 
communicate to providers, any information or instructions furnished to 
it by the Secretary, and serve as a channel of communication from 
providers to the Secretary; (B) to make such audits of the records of 
providers as may be necessary to insure that proper payments are made 
under this part; and (C) to perform such other functions as are 
necessary to carry out this subsection. As used in this subchapter and 
part B of subchapter XI of this chapter, the term ``fiscal 
intermediary'' means an agency or organization with a contract under 
this section.

(b) Prerequisites for agreement or renewal of agreement by Secretary

    The Secretary shall not enter into or renew an agreement with any 
agency or organization under this section unless--
        (1) he finds--
            (A) after applying the standards, criteria, and procedures 
        developed under subsection (f) of this section, that to do so is 
        consistent with the effective and efficient administration of 
        this part, and
            (B) that such agency or organization is willing and able to 
        assist the providers to which payments are made through it under 
        this part in the application of safeguards against unnecessary 
        utilization of services furnished by them to individuals 
        entitled to hospital insurance benefits under section 426 of 
        this title, and the agreement provides for such assistance; and

        (2) such agency or organization agrees--
            (A) to furnish to the Secretary such of the information 
        acquired by it in carrying out its agreement under this section, 
        and
            (B) to provide the Secretary with access to all such data, 
        information, and claims processing operations,

    as the Secretary may find necessary in performing his functions 
    under this part.

(c) Terms and conditions of agreements; prompt payment of claims

    (1) An agreement with any agency or organization under this section 
may contain such terms and conditions as the Secretary finds necessary 
or appropriate, may provide for advances of funds to the agency or 
organization for the making of payments by it under subsection (a) of 
this section, and shall provide for payment of so much of the cost of 
administration of the agency or organization as is determined by the 
Secretary to be necessary and proper for carrying out the functions 
covered by the agreement. The Secretary shall provide that in 
determining the necessary and proper cost of administration, the 
Secretary shall, with respect to each agreement, take into account the 
amount that is reasonable and adequate to meet the costs which must be 
incurred by an efficiently and economically operated agency or 
organization in carrying out the terms of its agreement. The Secretary 
shall cause to have published in the Federal Register, by not later than 
September 1 before each fiscal year, data, standards, and methodology to 
be used to establish budgets for fiscal intermediaries under this 
section for that fiscal year, and shall cause to be published in the 
Federal Register for public comment, at least 90 days before such data, 
standards, and methodology are published, the data, standards, and 
methodology proposed to be used. The Secretary may not require, as a 
condition of entering into or renewing an agreement under this section 
or under section 1395hh of this title, that a fiscal intermediary match 
data obtained other than in its activities under this part with data 
used in the administration of this part for purposes of identifying 
situations in which the provisions of section 1395y(b) of this title may 
apply.
    (2)(A) Each agreement under this section shall provide that payment 
shall be issued, mailed, or otherwise transmitted with respect to not 
less than 95 percent of all claims submitted under this subchapter--
        (i) which are clean claims, and
        (ii) for which payment is not made on a periodic interim payment 
    basis,

within the applicable number of calendar days after the date on which 
the claim is received.
    (B) In this paragraph:
        (i) The term ``clean claim'' means a claim that has no defect or 
    impropriety (including any lack of any required substantiating 
    documentation) or particular circumstance requiring special 
    treatment that prevents timely payment from being made on the claim 
    under this subchapter.
        (ii) The term ``applicable number of calendar days'' means--
            (I) with respect to claims received in the 12-month period 
        beginning October 1, 1986, 30 calendar days,
            (II) with respect to claims received in the 12-month period 
        beginning October 1, 1987, 26 calendar days,
            (III) with respect to claims received in the 12-month period 
        beginning October 1, 1988, 25 calendar days, and \1\
---------------------------------------------------------------------------
    \1\ So in original. The word ``and'' probably should not appear.
---------------------------------------------------------------------------
            (IV) with respect to claims received in the 12-month period 
        beginning October 1, 1989, and claims received in any succeeding 
        12-month period ending on or before September 30, 1993, 24 
        calendar days.\2\
---------------------------------------------------------------------------
    \2\ So in original. The period probably should be ``, and''.
---------------------------------------------------------------------------
            (V) with respect to claims received in the 12-month period 
        beginning October 1, 1993, and claims received in any succeeding 
        12-month period, 30 calendar days.

    (C) If payment is not issued, mailed, or otherwise transmitted 
within the applicable number of calendar days (as defined in clause (ii) 
of subparagraph (B)) after a clean claim (as defined in clause (i) of 
such subparagraph) is received from a hospital, critical access 
hospital, skilled nursing facility, home health agency, hospice program, 
comprehensive outpatient rehabilitation facility, or rehabilitation 
agency that is not receiving payments on a periodic interim payment 
basis with respect to such services, interest shall be paid at the rate 
used for purposes of section 3902(a) of title 31 (relating to interest 
penalties for failure to make prompt payments) for the period beginning 
on the day after the required payment date and ending on the date on 
which payment is made.
    (3)(A) Each agreement under this section shall provide that no 
payment shall be issued, mailed, or otherwise transmitted with respect 
to any claim submitted under this subchapter within the applicable 
number of calendar days after the date on which the claim is received.
    (B) In this paragraph, the term ``applicable number of calendar 
days'' means--
        (i) with respect to claims submitted electronically as 
    prescribed by the Secretary, 13 days, and
        (ii) with respect to claims submitted otherwise, 26 days.

(d) Nomination of agency or organization; withdrawal

    If the nomination of an agency or organization as provided in this 
section is made by a group or association of providers of services, it 
shall not be binding on members of the group or association which notify 
the Secretary of their election to that effect. Any provider may, upon 
such notice as may be specified in the agreement under this section with 
an agency or organization, withdraw its nomination to receive payments 
through such agency or organization. Any provider which has withdrawn 
its nomination, and any provider which has not made a nomination, may 
elect to receive payments from any agency or organization which has 
entered into an agreement with the Secretary under this section if the 
Secretary and such agency or organization agree to it.

(e) Assignment or reassignment of provider of services; designation of 
        agency or organization to perform provider services and home 
        health agency functions

    (1) Notwithstanding subsections (a) and (d) of this section, the 
Secretary, after taking into consideration any preferences of providers 
of services, may assign or reassign any provider of services to any 
agency or organization which has entered into an agreement with him 
under this section, if he determines, after applying the standards, 
criteria, and procedures developed under subsection (f) of this section, 
that such assignment or reassignment would result in the more effective 
and efficient administration of this part.
    (2) Notwithstanding subsections (a) and (d) of this section, the 
Secretary may (subject to the provisions of paragraph (4)) designate a 
national or regional agency or organization which has entered into an 
agreement with him under this section to perform functions under the 
agreement with respect to a class of providers of services in the Nation 
or region (as the case may be), if he determines, after applying the 
standards, criteria, and procedures developed under subsection (f) of 
this section, that such designation would result in more effective and 
efficient administration of this part.
    (3)(A) Before the Secretary makes an assignment or reassignment 
under paragraph (1) of a provider of services to other than the agency 
or organization nominated by the provider, he shall furnish (i) the 
provider and such agency or organization with a full explanation of the 
reasons for his determination as to the efficiency and effectiveness of 
the agency or organization to perform the functions required under this 
part with respect to the provider, and (ii) such agency or organization 
with opportunity for a hearing, and such determination shall be subject 
to judicial review in accordance with chapter 7 of title 5.
    (B) Before the Secretary makes a designation under paragraph (2) 
with respect to a class of providers of services, he shall furnish (i) 
such providers and the agencies and organizations adversely affected by 
such designation with a full explanation of the reasons for his 
determination as to the efficiency and effectiveness of such agencies 
and organizations to perform the functions required under this part with 
respect to such providers, and (ii) the agencies and organizations 
adversely affected by such designation with opportunity for a hearing, 
and such determination shall be subject to judicial review in accordance 
with chapter 7 of title 5.
    (4) Notwithstanding subsections (a) and (d) of this section and 
paragraphs (1), (2), and (3) of this subsection, the Secretary shall 
designate regional agencies or organizations which have entered into an 
agreement with him under this section to perform functions under such 
agreement with respect to home health agencies (as defined in section 
1395x(o) of this title) in the region, except that in assigning such 
agencies to such designated regional agencies or organizations the 
Secretary shall assign a home health agency which is a subdivision of a 
hospital (and such agency and hospital are affiliated or under common 
control) only if, after applying such criteria relating to 
administrative efficiency and effectiveness as he shall promulgate, he 
determines that such assignment would result in the more effective and 
efficient administration of this subchapter. By not later than July 1, 
1987, the Secretary shall limit the number of such regional agencies or 
organizations to not more than ten.
    (5) Notwithstanding any other provision of this subchapter, the 
Secretary shall designate the agency or organization which has entered 
into an agreement under this section to perform functions under such an 
agreement with respect to each hospice program, except that with respect 
to a hospice program which is a subdivision of a provider of services 
(and such hospice program and provider of services are under common 
control) due regard shall be given to the agency or organization which 
performs the functions under this section for the provider of services.

(f) Development of standards, criteria, and procedures by Secretary for 
        evaluation of agency or organization performance

    (1) In order to determine whether the Secretary should enter into, 
renew, or terminate an agreement under this section with an agency or 
organization, whether the Secretary should assign or reassign a provider 
of services to an agency or organization, and whether the Secretary 
should designate an agency or organization to perform services with 
respect to a class of providers of services, the Secretary shall develop 
standards, criteria, and procedures to evaluate such agency's or 
organization's (A) overall performance of claims processing (including 
the agency's or organization's success in recovering payments made under 
this subchapter for services for which payment has been or could be made 
under a primary plan (as defined in section 1395y(b)(2)(A) of this 
title)) and other related functions required to be performed by such an 
agency or organization under an agreement entered into under this 
section, and (B) performance of such functions with respect to specific 
providers of services, and the Secretary shall establish standards and 
criteria with respect to the efficient and effective administration of 
this part. No agency or organization shall be found under such standards 
and criteria not to be efficient or effective or to be less efficient or 
effective solely on the ground that the agency or organization serves 
only providers located in a single State.
    (2) The standards and criteria established under paragraph (1) shall 
include--
        (A) with respect to claims for services furnished under this 
    part by any provider of services other than a hospital--
            (i) whether such agency or organization is able to process 
        75 percent of reconsiderations within 60 days (except in the 
        case of fiscal year 1989, 66 percent of reconsiderations) and 90 
        percent of reconsiderations within 90 days, and
            (ii) the extent to which such agency's or organization's 
        determinations are reversed on appeal; and

        (B) with respect to applications for an exemption from or 
    exception or adjustment to the target amount applicable under 
    section 1395ww(b) of this title to a hospital that is not a 
    subsection (d) hospital (as defined in section 1395ww(d)(1)(B) of 
    this title)--
            (i) if such agency or organization receives a completed 
        application, whether such agency or organization is able to 
        process such application not later than 75 days after the 
        application is filed, and
            (ii) if such agency or organization receives an incomplete 
        application, whether such agency or organization is able to 
        return the application with instructions on how to complete the 
        application not later than 60 days after the application is 
        filed.

(g) Termination of agreement; procedures applicable

    An agreement with the Secretary under this section may be 
terminated--
        (1) by the agency or organization which entered into such 
    agreement at such time and upon such notice to the Secretary, to the 
    public, and to the providers as may be provided in regulations, or
        (2) by the Secretary at such time and upon such notice to the 
    agency or organization, to the providers which have nominated it for 
    purposes of this section, and to the public, as may be provided in 
    regulations, but only if he finds, after applying the standards, 
    criteria, and procedures developed under subsection (f) of this 
    section and after reasonable notice and opportunity for hearing to 
    the agency or organization, that (A) the agency or organization has 
    failed substantially to carry out the agreement, or (B) the 
    continuation of some or all of the functions provided for in the 
    agreement with the agency or organization is disadvantageous or is 
    inconsistent with the efficient administration of this part.

(h) Bonding requirement under agreement for officers and employees of 
        agency or organization

    An agreement with an agency or organization under this section may 
require any of its officers or employees certifying payments or 
disbursing funds pursuant to the agreement, or otherwise participating 
in carrying out the agreement, to give surety bond to the United States 
in such amount as the Secretary may deem appropriate.

(i) Liability of certifying and disbursing officers designated under 
        agreement for negligent, etc., payments

    (1) No individual designated pursuant to an agreement under this 
section as a certifying officer shall, in the absence of gross 
negligence or intent to defraud the United States, be liable with 
respect to any payments certified by him under this section.
    (2) No disbursing officer shall, in the absence of gross negligence 
or intent to defraud the United States, be liable with respect to any 
payment by him under this section if it was based upon a voucher signed 
by a certifying officer designated as provided in paragraph (1) of this 
subsection.
    (3) No such agency or organization shall be liable to the United 
States for any payments referred to in paragraph (1) or (2).

(j) Denial of claim; notification and reconsideration

    An agreement with an agency or organization under this section shall 
require that, with respect to a claim for home health services, extended 
care services, or post-hospital extended care services submitted by a 
provider to such agency or organization that is denied, such agency or 
organization--
        (1) furnish the provider and the individual with respect to whom 
    the claim is made with a written explanation of the denial and of 
    the statutory or regulatory basis for the denial; and
        (2) in the case of a request for reconsideration of a denial, 
    promptly notify such individual and the provider of the disposition 
    of such reconsideration.

(k) Annual reporting requirement on erroneous payment recovery

    An agreement with an agency or organization under this section shall 
require that such agency or organization submit an annual report to the 
Secretary describing the steps taken to recover payments made for items 
or services for which payment has been or could be made under a primary 
plan (as defined in section 1395y(b)(2)(A) of this title).

(l) No authority for activities carried out under Medicare Integrity 
        Program

    No agency or organization may carry out (or receive payment for 
carrying out) any activity pursuant to an agreement under this section 
to the extent that the activity is carried out pursuant to a contract 
under the Medicare Integrity Program under section 1395ddd of this 
title.

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1816, as added Pub. L. 89-97, 
title I, Sec. 102(a), July 30, 1965, 79 Stat. 297; amended Pub. L. 92-
603, title II, Sec. 243(b), Oct. 30, 1972, 86 Stat. 1422; Pub. L. 95-
142, Sec. 14(a), Oct. 25, 1977, 91 Stat. 1198; Pub. L. 96-499, title IX, 
Sec. 930(o), Dec. 5, 1980, 94 Stat. 2632; Pub. L. 97-248, title I, 
Sec. 122(c)(3), Sept. 3, 1982, 96 Stat. 359; Pub. L. 98-369, div. B, 
title III, Sec. 2326(b), (c)(1), (d)(1), July 18, 1984, 98 Stat. 1087; 
Pub. L. 99-509, title IX, Secs. 9311(b), 9352(a)(2), Oct. 21, 1986, 100 
Stat. 1997, 2044; Pub. L. 100-203, title IV, Secs. 4031(a)(1), 4032(a), 
(b), 4035(a)(1), 4085(d)(1), Dec. 22, 1987, 101 Stat. 1330-75 to 1330-
78, 1330-130; Pub. L. 100-360, title II, Sec. 203(f), title IV, 
Sec. 411(e)(1)(B), July 1, 1988, 102 Stat. 725, 775; Pub. L. 101-234, 
title II, Sec. 201(a), Dec. 13, 1989, 103 Stat. 1981; Pub. L. 101-239, 
title VI, Secs. 6003(g)(3)(D)(vi), 6202(d)(1), Dec. 19, 1989, 103 Stat. 
2153, 2234; Pub. L. 101-508, title IV, Sec. 4005(c)(1)(A), Nov. 5, 1990, 
104 Stat. 1388-41; Pub. L. 103-66, title XIII, Sec. 13568(a), (b), Aug. 
10, 1993, 107 Stat. 608; Pub. L. 103-432, title I, Secs. 110(d)(2), 
151(b)(1)(A), (2)(A), Oct. 31, 1994, 108 Stat. 4408, 4433, 4434; Pub. L. 
104-191, title II, Sec. 202(b)(1), Aug. 21, 1996, 110 Stat. 1998; Pub. 
L. 105-33, title IV, Sec. 4201(c)(1), Aug. 5, 1997, 111 Stat. 373.)

                       References in Text

    Part B of subchapter XI of this chapter, referred to in subsec. (a), 
is classified to section 1320c et seq. of this title.


                               Amendments

    1997--Subsec. (c)(2)(C). Pub. L. 105-33 substituted ``critical 
access'' for ``rural primary care''.
    1996--Subsec. (l). Pub. L. 104-191 added subsec. (l).
    1994--Subsec. (f)(1)(A). Pub. L. 103-432, Sec. 151(b)(2)(A), 
inserted ``(including the agency's or organization's success in 
recovering payments made under this subchapter for services for which 
payment has been or could be made under a primary plan (as defined in 
section 1395y(b)(2)(A) of this title))'' after ``processing''.
    Subsec. (f)(2)(A)(ii). Pub. L. 103-432, Sec. 110(d)(2), substituted 
``such agency's'' for ``such agency''.
    Subsec. (k). Pub. L. 103-432, Sec. 151(b)(1)(A), added subsec. (k).
    1993--Subsec. (c)(2)(B)(ii)(IV), (V). Pub. L. 103-66, Sec. 13568(b), 
substituted ``period ending on or before September 30, 1993'' for 
``period'' in subcl. (IV) and added subcl. (V).
    Subsec. (c)(3)(B). Pub. L. 103-66, Sec. 13568(a), added cls. (i) and 
(ii) and struck out former cls. (i) and (ii) which read as follows:
    ``(i) with respect to claims received in the 3-month period 
beginning July 1, 1988, 10 days, and
    ``(ii) with respect to claims received in the 12-month period 
beginning October 1, 1988, 14 days.''
    1990--Subsec. (f). Pub. L. 101-508 designated existing provisions as 
par. (1), redesignated former pars. (1) and (2) as subpars. (A) and (B), 
respectively, struck out ``Such standards and criteria'' and all that 
follows, which was executed by striking out ``Such standards and 
criteria shall be published in the Federal Register, and opportunity 
shall be provided for public comment prior to implementation. Such 
standards and criteria shall include with respect to claims for services 
furnished under this part by any provider of services other than a 
hospital whether such agency or organization is able to process 75 
percent of reconsiderations within 60 days (except in the case of the 
fiscal year 1989, 66 percent of reconsiderations) and 90 percent of 
reconsiderations within 90 days and the extent to which its 
determinations are reversed on appeal.'', and added par. (2).
    1989--Subsec. (c)(1). Pub. L. 101-239, Sec. 6202(d)(1), inserted at 
end ``The Secretary may not require, as a condition of entering into or 
renewing an agreement under this section or under section 1395hh of this 
title, that a fiscal intermediary match data obtained other than in its 
activities under this part with data used in the administration of this 
part for purposes of identifying situations in which the provisions of 
section 1395y(b) of this title may apply.''
    Subsec. (c)(2)(C). Pub. L. 101-239, Sec. 6003(g)(3)(D)(vi), inserted 
``rural primary care hospital,'' after ``hospital,''.
    Subsec. (k). Pub. L. 101-234 repealed Pub. L. 100-360, Sec. 203(f), 
and provided that the provisions of law amended or repealed by such 
section are restored or revived as if such section had not been enacted, 
see 1988 Amendment note below.
    1988--Subsec. (j)(2). Pub. L. 100-360, Sec. 411(e)(1)(B), inserted 
``in the case of a request for reconsideration of a denial,'' and 
substituted ``the disposition'' for ``disposition''.
    Subsec. (k). Pub. L. 100-360, Sec. 203(f), added subsec. (k) 
relating to use of regional intermediaries in administration of 
benefits.
    1987--Subsec. (c)(1). Pub. L. 100-203, Sec. 4035(a)(1), inserted at 
end ``The Secretary shall cause to have published in the Federal 
Register, by not later than September 1 before each fiscal year, data, 
standards, and methodology to be used to establish budgets for fiscal 
intermediaries under this section for that fiscal year, and shall cause 
to be published in the Federal Register for public comment, at least 90 
days before such data, standards, and methodology are published, the 
data, standards, and methodology proposed to be used.''
    Subsec. (c)(2)(C). Pub. L. 100-203, Sec. 4085(d)(1), substituted 
``hospice program, comprehensive outpatient rehabilitation facility, or 
rehabilitation agency'' for ``or hospice program''.
    Subsec. (c)(3). Pub. L. 100-203, Sec. 4031(a)(1), added par. (3).
    Subsec. (f). Pub. L. 100-203, Sec. 4023(b), inserted at end ``Such 
standards and criteria shall include with respect to claims for services 
furnished under this part by any provider of services other than a 
hospital whether such agency or organization is able to process 75 
percent of reconsiderations within 60 days (except in the case of the 
fiscal year 1989, 66 percent of reconsiderations) and 90 percent of 
reconsiderations within 90 days and the extent to which its 
determinations are reversed on appeal.''
    Subsec. (j). Pub. L. 100-203, Sec. 4032(a), added subsec. (j).
    1986--Subsec. (a). Pub. L. 99-509, Sec. 9352(a)(2), inserted at end 
``As used in this subchapter and part B of subchapter XI of this 
chapter, the term `fiscal intermediary' means an agency or organization 
with a contract under this section.''
    Subsec. (c). Pub. L. 99-509, Sec. 9311(b), designated existing 
provisions as par. (1) and added par. (2).
    1984--Subsec. (c). Pub. L. 98-369, Sec. 2326(d)(1), inserted 
provision that the Secretary, in determining the necessary and proper 
cost of administration with respect to each agreement, take into account 
the amount that is reasonable and adequate to meet the costs which must 
be incurred by an efficiently and economically operated agency or 
organization in carrying out the terms of its agreement.
    Subsec. (e)(4). Pub. L. 98-369, Sec. 2326(b), inserted provision 
that not later than July 1, 1987, the Secretary limit the number of 
regional agencies or organizations to not more than ten.
    Subsec. (f). Pub. L. 98-369, Sec. 2326(c)(1), struck out in cl. (2) 
``, by regulation,'' after ``Secretary shall establish'' and inserted 
provision that the standards and criteria be published in the Federal 
Register and an opportunity be provided for public comment prior to 
implementation.
    1982--Subsec. (e)(5). Pub. L. 97-248 added par. (5).
    1980--Subsec. (e)(2). Pub. L. 96-499, Sec. 930(o)(1), inserted 
``(subject to the provisions of paragraph (4))''.
    Subsec. (e)(4). Pub. L. 96-499, Sec. 930(o)(2), added par. (4).
    1977--Subsec. (a). Pub. L. 95-142, Sec. 14(a)(1), inserted 
provisions relating to applicability to providers assigned to the agency 
or organization under subsec. (e) of this section.
    Subsec. (b). Pub. L. 95-142, Sec. 14(a)(2), substituted provisions 
setting forth criteria for agreements by the Secretary or renewal of 
such agreements with agencies or organizations, for provisions setting 
forth criteria for agreements by the Secretary with agencies or 
organizations.
    Subsecs. (e), (f). Pub. L. 95-142, Sec. 14(a)(4), (5), added 
subsecs. (e) and (f). Former subsecs. (e) and (f) redesignated (g) and 
(h), respectively.
    Subsec. (g). Pub. L. 95-142, Sec. 14(a)(3), (4), redesignated former 
subsec. (e) as (g) and inserted provisions relating to applicability of 
standards, etc., developed under subsec. (f) of this section. Former 
subsec. (g) redesignated (i).
    Subsecs. (h), (i). Pub. L. 95-142, Sec. 14(a)(4), redesignated 
former subsecs. (f) and (g) as (h) and (i), respectively.
    1972--Subsec. (a). Pub. L. 92-603 inserted reference to provisions 
of section 1395oo of this title.


                    Effective Date of 1997 Amendment

    Amendment by Pub. L. 105-33 applicable to services furnished on or 
after Oct. 1, 1997, see section 4201(d) of Pub. L. 105-33, set out as a 
note under section 1395f of this title.


                    Effective Date of 1994 Amendment

    Section 151(b)(4) of Pub. L. 103-432 provided that: ``The amendments 
made by paragraphs (1) and (2) [amending this section and section 1395u 
of this title] shall apply to contracts with fiscal intermediaries and 
carriers under title XVIII of the Social Security Act [this subchapter] 
for contract years beginning with 1995.''


                    Effective Date of 1993 Amendment

    Section 13568(c) of Pub. L. 103-66 provided that: ``The amendments 
made by this section [amending this section and section 1395u of this 
title] shall apply to claims received on or after October 1, 1993.''


                    Effective Date of 1989 Amendments

    Section 6202(d)(3) of Pub. L. 101-239 provided that: ``The 
amendments made by this subsection [amending this section and section 
1395u of this title] shall apply to agreements and contracts entered 
into or renewed on or after the date of the enactment of this Act [Dec. 
19, 1989].''
    Amendment by Pub. L. 101-234 effective Jan. 1, 1990, see section 
201(c) of Pub. L. 101-234, set out as a note under section 1320a-7a of 
this title.


                    Effective Date of 1988 Amendment

    Amendment by section 203(f) of Pub. L. 100-360 applicable to items 
and services furnished on or after Jan. 1, 1990, see section 203(g) of 
Pub. L. 100-360, set out as a note under section 1320c-3 of this title.
    Except as specifically provided in section 411 of Pub. L. 100-360, 
amendment by section 411(e)(1)(B) of Pub. L. 100-360, as it relates to a 
provision in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-
203, effective as if included in the enactment of that provision in Pub. 
L. 100-203, see section 411(a) of Pub. L. 100-360, set out as a 
Reference to OBRA; Effective Date note under section 106 of Title 1, 
General Provisions.


                    Effective Date of 1987 Amendment

    Section 4031(a)(3)(A) of Pub. L. 100-203 provided that: ``The 
amendments made by paragraphs (1) and (2) [amending this section and 
section 1395u of this title] shall apply to claims received on or after 
July 1, 1988.''
    Section 4032(c)(1) of Pub. L. 100-203, as amended by Pub. L. 100-
360, title IV, Sec. 411(e)(1)(C), July 1, 1988, 102 Stat. 775, provided 
that:
    ``(A) The amendment made by subsection (a) [amending this section] 
shall apply with respect to claims received on or after January 1, 1988.
    ``(B) The amendment made by subsection (b) [amending this section] 
shall apply with respect to reconsiderations requested on or after 
October 1, 1988.''
    Section 4035(a)(3) of Pub. L. 100-203 provided that: ``The 
amendments made by this section [amending this section and sections 
1395u and 1395hh of this title] shall take effect on the date of the 
enactment of this Act [Dec. 22, 1987] and shall apply to budgets for 
fiscal years beginning with fiscal year 1989.''
    Section 4085(d)(2) of Pub. L. 100-203 provided that:
    ``(A) The amendment made by paragraph (1) [amending this section] 
shall apply to claims received on or after the date of enactment of this 
Act [Dec. 22, 1987].
    ``(B) The Secretary of Health and Human Services shall provide for 
such timely amendments to agreements under section 1816 [this section], 
and regulations, to such extent as may be necessary to implement the 
amendment made by paragraph (1).''


                    Effective Date of 1986 Amendment

    Section 9311(d) of Pub. L. 99-509 provided that:
    ``(1) Except as provided in paragraph (2), the amendments made by 
subsections (b) and (c) [amending this section and section 1395u of this 
title] shall apply to claims received on or after November 1, 1986.
    ``(2) Sections 1816(c)(2)(C)) [sic] and 1842(c)(2)(C) of the Social 
Security Act [subsec. (c)(2)(C) of this section and section 
1395u(c)(2)(C) of this title], as added by such amendments, shall apply 
to claims received on or after April 1, 1987.
    ``(3) The Secretary of Health and Human Services shall provide for 
such timely amendments to agreements under section 1816 of the Social 
Security Act [this section] and contracts under section 1842 of such Act 
[section 1395u of this title], and regulations, to such extent as may be 
necessary to implement the provisions of this Act on a timely basis.''
    Amendment by section 9352(a)(2) of Pub. L. 99-509 to be implemented 
by Secretary of Health and Human Services not later than 6 months after 
Oct. 21, 1986, see section 9352(c)(1) of Pub. L. 99-509, set out as a 
note under section 1320c-2 of this title.


                    Effective Date of 1984 Amendment

    Section 2326(d)(3) of Pub. L. 98-369 provided that: ``The amendments 
made by this subsection [amending this section and section 1395u of this 
title] shall apply to agreements and contracts entered into or renewed 
after September 30, 1984.''


                    Effective Date of 1982 Amendment

    Amendment by Pub. L. 97-248 applicable to hospice care provided on 
or after Nov. 1, 1983, see section 122(h)(1) of Pub. L. 97-248, as 
amended, set out as a note under section 1395c of this title.


                    Effective Date of 1980 Amendment

    Amendment by Pub. L. 96-499 effective Dec. 5, 1980, see section 
930(s)(1) of Pub. L. 96-499, set out as a note under section 1395x of 
this title.


                    Effective Date of 1977 Amendment

    Section 14(c), (d) of Pub. L. 95-142 provided that:
    ``(c) The amendment made by paragraphs (2) and (3) of subsection (a) 
[amending this section] to the extent that they require application of 
standards, criteria, and procedures developed under section 1816(f) of 
the Social Security Act [subsec. (f) of this section] shall apply to the 
entering into, renewal, or termination of agreements on and after 
October 1, 1978.
    ``(d) Except as provided in subsection (c), the amendment made by 
subsection (a)(2) [amending this section] shall apply to agreements 
entered into or renewed on or after the date of enactment of this Act 
[Oct. 25, 1977].''


                    Effective Date of 1972 Amendment

    Amendment by Pub. L. 92-603 applicable with respect to cost reports 
of providers of services for accounting periods ending on or after June 
30, 1973, see section 243(c) of Pub. L. 92-603, set out as an Effective 
Date note under section 1395oo of this title.


            Advisory Committee on Medicare Home Health Claims

    Section 427 of Pub. L. 100-360, which provided that the 
Administrator of the Health Care Financing Administration was to 
establish an advisory committee to be known as the Advisory Committee on 
Medicare Home Health Claims to study the reasons for the increase in the 
denial of claims for home health services during 1986 and 1987, the 
ramifications of such increase, and the need to reform the process 
involved in such denials, was repealed by Pub. L. 101-234, title III, 
Sec. 301(a), Dec. 13, 1989, 103 Stat. 1985.


 Amendments to Agreements and Contracts Necessary To Implement Section 
                       4031(a) of Pub. L. 100-203

    Section 4031(a)(3)(B) of Pub. L. 100-203 provided that: ``The 
Secretary of Health and Human Services shall provide for such timely 
amendments to agreements under section 1816 of the Social Security Act 
[this section] and contracts under section 1842 of such Act [section 
1395u of this title], and regulations, to such extent as may be 
necessary to implement the provisions of this subsection [amending this 
section and section 1395u of this title] on a timely basis.''


 Prohibition of Policies Other Than as Provided by Section 4031 of Pub. 
       L. 100-203 Intended To Slow Down Medicare Payments; Budget 
                             Considerations

    Section 4031(b), (c) of Pub. L. 100-203 provided that:
    ``(b) Prohibition of Other Policies Intended to Slow Down Medicare 
Payments.--Notwithstanding any other provision of law, except as 
specifically provided in this section [amending this section and section 
1395u of this title and enacting provisions set out as notes under this 
section], the Secretary of Health and Human Services is not authorized 
to issue, after the date of the enactment of this Act [Dec. 22, 1987], 
and before October 1, 1990, any final regulation, instruction, or other 
policy change which is primarily intended to have the effect of slowing 
down claims processing, or delaying payment of claims, under title XVIII 
of the Social Security Act [this subchapter].
    ``(c) Budget Considerations.--For purposes of section 202 of the 
Balanced Budget and Emergency Deficit Control Reaffirmation Act of 1987 
[2 U.S.C. 909], this section is a necessary (but secondary) result of a 
significant policy change.''


 Amendments to Agreements and Contracts Necessary To Implement Section 
                     4032(a), (b) of Pub. L. 100-203

    Section 4032(c)(2) provided that: ``The Secretary of Health and 
Human Services shall provide for such timely amendments to agreements 
under section 1816 [this section] and contracts under section 1842 of 
the Social Security Act [section 1395u of this title], and regulations, 
to such extent as may be necessary to implement the amendments made by 
subsections (a) and (b) [amending this section] on a timely basis.''


  Replacement of Agency, Organization, or Carrier Processing Medicare 
 Claims; Number of Agreements and Contracts Authorized for Fiscal Years 
                            1985 Through 1993

    Section 2326(a) of Pub. L. 98-369, as amended by Pub. L. 98-617, 
Sec. 3(a)(2), Nov. 8, 1984, 98 Stat. 3295; Pub. L. 99-509, title IX, 
Sec. 9321(b), Oct. 21, 1986, 100 Stat. 2016; Pub. L. 101-239, title VI, 
Sec. 6215(a), Dec. 19, 1989, 103 Stat. 2252; Pub. L. 103-432, title I, 
Sec. 159(a), Oct. 31, 1994, 108 Stat. 4443, provided that: ``During each 
fiscal year (beginning with fiscal year 1985 and ending with fiscal year 
1993), the Secretary of Health and Human Services may enter into not 
more than two agreements under section 1816 of the Social Security Act 
[this section], and not more than two contracts under section 1842 of 
such Act [section 1395u of this title], on the basis of competitive 
bidding, without regard to the nominating process under section 1816(a) 
of such Act or cost reimbursement provisions under sections 1816(c) or 
1842(c) of such Act during the term of the agreement. Such procedure may 
be used only for the purpose of replacing an agency or organization or 
carrier which over a 2-year period of time has been in the lowest 20th 
percentile of agencies and organizations or carriers having agreements 
or contracts under the respective section, as measured by the 
Secretary's cost and performance criteria. In addition, beginning with 
fiscal year 1990 and any subsequent fiscal year the Secretary may enter 
into such additional agreements and contracts without regard to such 
cost reimbursement provisions if the fiscal intermediary or carrier 
involved and the Secretary agree to waive such provisions, but the 
Secretary may not take any action that has the effect of requiring that 
the intermediary or carrier agree to waive such provisions, including 
requiring such a waiver as a condition for entering into or renewing 
such an agreement or contract. Any agency or organization or carrier 
selected on the basis of competitive bidding must perform all of the 
duties listed in section 1816(a) of such Act, or the duties listed in 
paragraphs (1) through (4) of section 1842(a) of such Act, as the case 
may be, and must be a health insuring organization (as determined by the 
Secretary).''
    [Section 159(b) of Pub. L. 103-432 provided that: ``The amendment 
made by subsection (a) [amending section 2326(a) of Pub. L. 98-369, set 
out above] shall apply beginning with fiscal year 1994.'']
    [Section 6215(b) of Pub. L. 101-239 provided that: ``The amendments 
made by subsection (a) [amending section 2326(a) of Pub. L. 98-369, set 
out above] shall apply beginning with fiscal year 1990.'']


                     Audit and Medical Claims Review

    Section 118 of Pub. L. 97-248, as amended by Pub. L. 99-272, title 
IX, Sec. 9216(a), Apr. 7, 1986, 100 Stat. 180, provided that: ``In 
addition to any funds otherwise provided for payments to intermediaries 
and carriers under agreements entered into under sections 1816 and 1842 
of the Social Security Act [this section and section 1395u of this 
title], there are transferred from the Federal Hospital Insurance Trust 
Fund and the Federal Supplementary Medical Insurance Fund in such 
proportions as the Secretary of Health and Human Services determines to 
be appropriate, an additional $45,000,000 for each of fiscal years 1983, 
1984, and 1985, and $105,000,000 for each of fiscal years 1986, 1987, 
and 1988 for payments to such intermediaries and carriers under such 
agreements to be used exclusively for purposes of carrying out provider 
cost audits, of reviewing medical necessity, and of recovering third-
party liability payments, consistent with the provisions of sections 
1816 and 1842 of the Social Security Act.''
    [Section 9216(b) of Pub. L. 99-272 provided that: ``The amendments 
made by subsection (a) [amending section 118 of Pub. L. 97-248, set out 
above] shall apply to fiscal years beginning with fiscal year 1986.'']


 Developmental Date for Standards, Criteria, and Procedures Pursuant to 
                       Subsec. (f) of This Section

    Section 14(b) of Pub. L. 95-142 directed the Secretary of Health, 
Education, and Welfare to develop the standards, criteria, and 
procedures described in subsection (f) of section 1816 of the Social 
Security Act [subsec. (f) of this section] (as added by subsection 
(a)(5)) not later than Oct. 1, 1978.

                  Section Referred to in Other Sections

    This section is referred to in sections 1320a-3, 1320c-2, 1320c-3, 
1395g, 1395u, 1395w-27, 1395hh, 1395mm, 1395oo, 1395pp, 1395ddd of this 
title.
