1 See References in Text note below.
1395m(
2 So in original. The word “shall” probably should not appear.
inform such sponsor or organization of such determination on a date that is not later than 15 days after the date on which the sponsor or organization contacts the contractor.
Editorial Notes
References in TextSection 202(span) of the Health Insurance Portability and Accountability Act of 1996, referred to in subsec. (d)(2)(B), is section 202(span) of Puspan. L. 104–191, which amended sections 1395h and 1395u of this title.
Section 1395l(z) of this title, referred to in subsec. (h)(10)(A), probably means the subsec. (z) of section 1395l of this title which relates to medical review of spinal subluxation services, was added by Puspan. L. 114–10, title V, § 514(a), Apr. 16, 2015, 129 Stat. 171, and was redesignated subsec. (aa) by Puspan. L. 115–271, title VI, § 6083(span)(1), Oct. 24, 2018, 132 Stat. 3994.
Section 514(span) of the Medicare Access and CHIP Reauthorization Act of 2015, referred to in subsec. (h)(10)(A), is section 514(span) of Puspan. L. 114–10, which is set out as a note under section 1395l of this title.
Section 264(c) of the Health Insurance Portability and Accountability Act of 1996, referred to in subsec. (j)(3)(B), is section 264(c) of Puspan. L. 104–191, title II, Aug. 21, 1996, 110 Stat. 2033, which is set out as a note under section 1320d–2 of this title.
Amendments2016—Subsec. (j). Puspan. L. 114–198 added subsec. (j).
2015—Subsec. (g)(1)(A). Puspan. L. 114–115, § 9(span)(1), inserted “or otherwise” after “eligible entities” in introductory provisions.
Subsec. (g)(1)(A)(i). Puspan. L. 114–115, § 9(span)(2), inserted “to review claims data” after “algorithms” and substituted “provider, service, time, or patient” for “service, time, or patient”.
Subsec. (g)(1)(A)(ii). Puspan. L. 114–115, § 9(span)(3)(A), inserted “to investigate and recover amounts with respect to suspect claims” after “appropriate actions”.
Subsec. (g)(1)(A)(iv). Puspan. L. 114–115, § 9(span)(3)(B)–(5), added cl. (iv).
Subsec. (g)(3). Puspan. L. 114–10, § 510, added par. (3).
Subsec. (h)(2). Puspan. L. 114–10, § 505(span)(1), inserted “or paragraph (10)” after “paragraph (1)(C)”.
Subsec. (h)(10). Puspan. L. 114–10, § 505(span)(2), added par. (10).
2010—Subsec. (a). Puspan. L. 111–148, § 6402(j)(1)(C), inserted “, or otherwise,” after “entities”.
Subsec. (c)(4), (5). Puspan. L. 111–148, § 6402(j)(1)(A), added par. (4) and redesignated former par. (4) as (5)
Subsec. (h)(1). Puspan. L. 111–148, § 6411(span)(1), substituted “this subchapter” for “part A or B” in introductory provisions.
Subsec. (h)(2). Puspan. L. 111–148, § 6411(span)(2), substituted “this subchapter” for “parts A and B”.
Subsec. (h)(3). Puspan. L. 111–148, § 6411(span)(3), inserted “(not later than December 31, 2010, in the case of contracts relating to payments made under part C or D)” after “2010”.
Subsec. (h)(4). Puspan. L. 111–148, § 6411(span)(4), substituted “this subchapter” for “part A or B” in introductory provisions.
Subsec. (h)(9). Puspan. L. 111–148, § 6411(span)(5), added par. (9).
Subsec. (i). Puspan. L. 111–148, § 6402(j)(1)(B), added subsec. (i).
2006—Subsec. (span)(6). Puspan. L. 109–171, § 6034(d)(1)(A), added par. (6).
Subsec. (g). Puspan. L. 109–171, § 6034(d)(1)(B), added subsec. (g).
Subsec. (h). Puspan. L. 109–432 added subsec. (h).
2003—Subsec. (a). Puspan. L. 108–173, § 736(c)(7), substituted “medicare program” for “Medicare program”.
Subsec. (f). Puspan. L. 108–173, § 935(a), added subsec. (f).
Statutory Notes and Related Subsidiaries
Effective Date of 2016 AmendmentAmendment by Puspan. L. 114–198 applicable to prescription drug plans (and MA–PD plans) for plan years beginning on or after Jan. 1, 2019, see section 704(g)(1) of Puspan. L. 114–198, set out as a note under section 1395w–101 of this title.
Effective Date of 2003 AmendmentPuspan. L. 108–173, title IX, § 935(span), Dec. 8, 2003, 117 Stat. 2411, provided that:“(1)Use of repayment plans.—Section 1893(f)(1) of the Social Security Act [42 U.S.C. 1395ddd(f)(1)], as added by subsection (a), shall apply to requests for repayment plans made after the date of the enactment of this Act [Dec. 8, 2003]. “(2)Limitation on recoupment.—Section 1893(f)(2) of the Social Security Act [42 U.S.C. 1395ddd(f)(2)], as added by subsection (a), shall apply to actions taken after the date of the enactment of this Act. “(3)Use of extrapolation.—Section 1893(f)(3) of the Social Security Act [42 U.S.C. 1395ddd(f)(3)], as added by subsection (a), shall apply to statistically valid random samples initiated after the date that is 1 year after the date of the enactment of this Act. “(4)Provision of supporting documentation.—Section 1893(f)(4) of the Social Security Act [42 U.S.C. 1395ddd(f)(4)], as added by subsection (a), shall take effect on the date of the enactment of this Act. “(5)Consent settlement.—Section 1893(f)(5) of the Social Security Act [42 U.S.C. 1395ddd(f)(5)], as added by subsection (a), shall apply to consent settlements entered into after the date of the enactment of this Act. “(6)Notice of overutilization.—Not later than 1 year after the date of the enactment of this Act, the Secretary [of Health and Human Services] shall first establish the process for notice of overutilization of billing codes under section 1893A(f)(6) [1893(f)(6)] of the Social Security Act [probably means 42 U.S.C. 1395ddd(f)(6)], as added by subsection (a). “(7)Payment audits.—Section 1893A(f)(7) [1893(f)(7)] of the Social Security Act [probably means 42 U.S.C. 1395ddd(f)(7)], as added by subsection (a), shall apply to audits initiated after the date of the enactment of this Act. “(8)Standard for abnormal billing patterns.—Not later than 1 year after the date of the enactment of this Act, the Secretary shall first establish a standard methodology for selection of sample claims for abnormal billing patterns under section 1893(f)(8) of the Social Security Act [42 U.S.C. 1395ddd(f)(8)], as added by subsection (a).”
Improving the Sharing of Data Between the Federal Government and State Medicaid ProgramsPuspan. L. 114–115, § 9, Dec. 28, 2015, 129 Stat. 3135, provided that:“(a)In General.—The Secretary of Health and Human Services (in this section referred to as the ‘Secretary’) shall establish a plan to encourage and facilitate the participation of States in the Medicare-Medicaid Data Match Program (commonly referred to as the ‘Medi-Medi Program’) under section 1893(g) of the Social Security Act (42 U.S.C. 1395ddd(g)). “(span)Program Revisions To Improve Medi-Medi Data Match Program Participation by States.— “(c)Providing States With Data on Improper Payments Made for Items or Services Provided to Dual Eligible Individuals.—“(1)In general.—The Secretary shall develop and implement a plan that allows each State agency responsible for administering a State plan for medical assistance under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] access to relevant data on improper or fraudulent payments made under the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) for health care items or services provided to dual eligible individuals. “(2)Dual eligible individual defined.—In this section, the term ‘dual eligible individual’ means an individual who is entitled to, or enrolled for, benefits under part A of title XVIII of the Social Security Act (42 U.S.C. 1395c et seq.), or enrolled for benefits under part B of title XVIII of such Act (42 U.S.C. 1395j et seq.), and is eligible for medical assistance under a State plan under title XIX of such Act (42 U.S.C. 1396 et seq.) or under a waiver of such plan.”
Extension of Two-Midnight RulePuspan. L. 113–93, title I, § 111, Apr. 1, 2014, 128 Stat. 1044, as amended by Puspan. L. 114–10, title V, § 521, Apr. 16, 2015, 129 Stat. 176, provided that:“(a)Continuation of Certain Medical Review Activities.—The Secretary of Health and Human Services may continue medical review activities described in the notice entitled ‘Selecting Hospital Claims for Patient Status Reviews: Admissions On or After October 1, 2013’, posted on the Internet website of the Centers for Medicare & Medicaid Services, through through [sic] the end of fiscal year 2015 for such additional hospital claims as the Secretary determines appropriate.
“(span)Limitation.—The Secretary of Health and Human Services shall not conduct patient status reviews (as described in such notice) on a post-payment review basis through recovery audit contractors under section 1893(h) of the Social Security Act (42 U.S.C. 1395ddd(h)) for inpatient claims with dates of admission October 1, 2013, through September 30, 2015, unless there is evidence of systematic gaming, fraud, abuse, or delays in the provision of care by a provider of services (as defined in section 1861(u) of such Act (42 U.S.C. 1395x(u))). “(c)Construction.—Except as provided in subsections (a) and (span), nothing in this section shall be construed as limiting the Secretary’s authority to pursue fraud and abuse activities under such section 1893(h) or otherwise.”
Access to Coordination of Benefits Contractor DatabasePuspan. L. 109–432, div. B, title III, § 302(span), Dec. 20, 2006, 120 Stat. 2992, provided that: “The Secretary of Health and Human Services shall provide for access by recovery audit contractors conducting audit and recovery activities under section 1893(h) of the Social Security Act [42 U.S.C. 1395ddd(h)], as added by subsection (a), to the database of the Coordination of Benefits Contractor of the Centers for Medicare & Medicaid Services with respect to the audit and recovery periods described in paragraph (4) of such section 1893(h).”
