Sec. 6. Requirement for physician validation for medical necessity denials
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Section 1893(h) of the Social Security Act (42 U.S.C. 1395ddd(h)), as amended by sections 3(a), 4(a), and 6(a)(1), is further amended by adding at the end the following new paragraph: Each contract under this section for a recovery audit contractor shall require that a physician (as defined in section 1861(r)(1)) review each denial of a claim for medical necessity when a medical necessity review of such claim is performed and a denial is made by an employee of the contractor who is not a physician (as so defined). A physician reviewing a claim under subparagraph
(A)shall— make a determination whether the denial of the claim under the medical necessity review by the non-physician employee is appropriate; sign and certify such determination; and append such signed and certified determination to the claim file. A claim with respect to which a denial has been made as described in subparagraph
(A)for which the physician determines the denial is not appropriate under subparagraph
(B)shall be deemed to be medically necessary. In this paragraph, the term medical necessity review means, with respect to an audit of a claim of a provider of services or supplier, a review conducted by a recovery audit contractor for the purpose of determining whether an item or service furnished for which the claim is filed by such provider of services or supplier is reasonable and necessary for the diagnosis or treatment of illness or injury under section 1862(a)(1)(A). . Subsection
(h)of section 1874A of the Social Security Act ( 42 U.S.C. 1395kk–1 ), as added by section 3(b) and as amended by subsections (a)(2) and (b)(2) of section 6, is further amended by adding at the end the following new paragraph: A physician (as defined in section 1861(r)(1)) shall review each denial of a claim for medical necessity when a medical necessity review of such claim is performed and a denial is made by an employee of the contractor who is not a physician (as so defined). A physician reviewing a claim under subparagraph
(A)shall— make a determination whether the denial of the claim under the medical necessity review by the non-physician employee is appropriate; sign and certify such determination; and append such signed and certified determination to the claim file. A claim with respect to which a denial has been made as described in subparagraph
(A)for which the physician determines the denial is not appropriate under subparagraph
(B)shall be deemed to be medically necessary. In this paragraph, the term medical necessity review means, with respect to an audit of a claim of a provider of services or supplier, a review conducted by a medicare administrative contractor for the purpose of determining whether an item or service furnished for which the claim is filed by such provider of services or supplier is reasonable and necessary for the diagnosis or treatment of illness or injury under section 1862(a)(1)(A). . The Secretary of Health and Human Services shall require under each contract with a Comprehensive Error Rate Testing
(CERT)program contractor to review error rates under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ) that the CERT program contractor ensure that a physician (as defined in section 1861(r)(1) of such Act ( 42 U.S.C. 1395x(r)(1) )) reviews each denial of a claim for medical necessity when a medical necessity review of such claim is performed and a denial is made by an employee of the contractor who is not a physician (as so defined). A physician reviewing a claim under paragraph
(1)shall— make a determination whether the denial of the claim under the medical necessity review by the non-physician employee is appropriate; sign and certify such determination; and append such signed and certified determination to the claim file. A claim with respect to which a denial has been made as described in paragraph
(1)for which the physician determines the denial is not appropriate under paragraph
(2)shall be deemed to be medically necessary. In this subsection, the term medical necessity review means, with respect to an audit of a claim of a provider of services or supplier, a review conducted by a CERT program contractor for the purpose of determining whether an item or service furnished for which the claim is filed by such provider of services or supplier is reasonable and necessary for the diagnosis or treatment of illness or injury under section 1862(a)(1)(A) of the Social Security Act (42 U.S.C. 1395y(a)(1)(A)). The amendments made by subsections
(a)and (b), and the provisions of subsection (c), shall apply to contracts entered into or renewed with recovery audit contractors under section 1893(h) of the Social Security Act ( 42 U.S.C. 1395ddd(h) ), medicare administrative contractors under section 1874A of the Social Security Act ( 42 U.S.C. 1395kk–1 ) and Comprehensive Error Rate Testing
(CERT)program contractors, respectively, on or after the date of the enactment of this Act.
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- 42 USC 1395kk–1
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Sec. 6
Requirement for physician validation for medical necessity denials
Cite42 USC 1395kk–1
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