Sec. 5. Accurate payment for rebilled claims

1,389 words·~6 min read·/bill/113/s/1012/is/section-5

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

Section 1893(h) of the Social Security Act (42 U.S.C. 1395ddd(h)), as amended by sections 3(a) and 4(a), is further amended by adding at the end the following new paragraph: The resubmission of a specified claim (as defined in subparagraph (C)) shall be deemed to be an original claim for purposes of— payment under part B; and provisions under this title relating to— the authority of a hospital to resubmit a claim for payment under the appropriate section of this title; and requirements for the timely submission of claims, including under sections 1814(a), 1842(b)(3), and 1835(a). Payment shall be made for a specified claim resubmitted under subparagraph

(A)for all the items and services furnished for which payment may be made under part B. In this paragraph: The term specified claim means a claim submitted by a hospital for payment under part A for inpatient hospital services which a recovery audit contractor (or entity adjudicating a provider appeal of a Medicare claim denied payment by a recovery audit contractor) determines, subject to subclause (II), that the inpatient hospital services were not medically necessary and reasonable under section 1862(a)(1)(A). A recovery audit contractor or entity adjudicating such provider appeal shall, before completing a determination described in subclause (I), assess and make a specific finding as to whether the denied inpatient hospital services were medically necessary and reasonable in an outpatient setting of the hospital. The term resubmission includes, with respect to a specified claim of a hospital, the submission by the hospital of a new claim or of an adjusted original claim. . Subsection

(h)of section 1874A of the Social Security Act ( 42 U.S.C. 1395kk–1 ), as added by section 3(b), is further amended by adding at the end the following new paragraph: The resubmission of a specified claim (as defined in subparagraph (C)) shall be deemed to be an original claim for purposes of— payment under part B; and provisions under this title relating to— the authority of a hospital to resubmit a claim for payment under the appropriate section of this title; and requirements for the timely submission of claims, including under sections 1814(a), 1842(b)(3), and 1835(a). Payment shall be made for a specified claim resubmitted under subparagraph

(A)for all the items and services furnished for which payment may be made under part B. In this paragraph: The term specified claim means a claim submitted by a hospital for payment under part A for inpatient hospital services which a medicare administrative contractor (or entity adjudicating a hospital appeal of a Medicare claim denied payment by a medicare administrative contractor) determines, subject to subclause (II), that the inpatient hospital services were not medically necessary and reasonable under section 1862(a)(1)(A). A medicare administrative contractor or entity adjudicating such provider appeal shall, before completing a determination described in subclause (I), assess and make a specific finding as to whether the denied inpatient hospital services were medically necessary and reasonable in an outpatient setting of the hospital. The term resubmission includes, with respect to a specified claim of a hospital, the submission by the hospital of a new claim or of an adjusted original claim. . A Comprehensive Error Rate Testing

(CERT)program contractor with a contract with the Secretary of Health and Human Services to review error rates under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ) shall deem the resubmission of a specified claim (as defined in subparagraph (C)) as an original claim for purposes of— payment under part B of such title XVII; and provisions under such title relating to— the authority of a hospital to resubmit a claim for payment under the appropriate section of such title; and requirements for the timely submission of claims, including under sections 1814(a), 1842(b)(3), and 1835(a) of such Act ( 42 U.S.C. 1395f(a) , 1395u(b)(3), and 1395n(a), respectively). Payment shall be made for a specified claim resubmitted under subparagraph

(A)for all the items and services furnished for which payment may be made under part B of such title XVIII. In this paragraph: The term specified claim means a claim submitted by a hospital (as defined in section 1861(e) of such Act (42 U.S.C. 1395x(e))) for payment under title XVIII of such Act for inpatient hospital services which a Comprehensive Error Rate Testing

(CERT)program contractor (or entity adjudicating a hospital appeal of a Medicare claim denied payment by a CERT program contractor) determines the inpatient hospital services were not medically necessary and reasonable under section 1862(a)(1)(A) of such Act (42 U.S.C. 1395y(a)(1)(A)). A CERT program contractor or entity adjudicating such provider appeal shall, before completing a determination described in subclause (I), assess and make a specific finding as to whether the denied inpatient hospital services were medically necessary and reasonable in an outpatient setting of the hospital. The term resubmission includes, with respect to a specified claim of a hospital, the submission by the hospital of a new claim or of an adjusted original claim. The amendments made by paragraphs

(1)and (2), and the provisions of paragraph (3), 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. Section 1893(h)(4) of the Social Security Act (42 U.S.C. 1395ddd(h)(4)) is amended by adding after and below subparagraph

(B)the following: For purposes of the ability of a hospital to resubmit a claim for payment under the appropriate section of this title and for purposes of requirements for the timely submission of claims by hospitals, including under sections 1814(a), 1842(b)(3), and 1835(a), any claim that is the subject of an audit by a recovery audit contractor with a contract under this section shall be deemed to be a reopened claim. Such reopened claims are not subject to the timely filing limitations under such sections (and related regulations) and shall be adjusted and paid without regard to such timely filing limitations. . Section 1874A(h) of the Social Security Act ( 42 U.S.C. 1395kk–1(h) ), as added by section 3(b) and as amended by subsection (a)(2), is further amended by adding at the end the following new paragraph: For purposes of the ability of a hospital to resubmit a claim for payment under the appropriate provisions of this title and for purposes of requirements for the timely submission of claims by hospitals, including under sections 1814(a), 1842(b)(3), and 1835(a), any claim that is the subject of an audit by a medicare administrative contractor with a contract under this section shall be deemed to be a reopened claim. Such reopened claims are not subject to the timely filing limitations under such sections (and related regulations) and shall be adjusted and paid without regard to such timely filing limitations. . Any claim made for payment for services furnished by a hospital under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) that is the subject of an audit by a Comprehensive Error Rate Testing

(CERT)program contractor with a contract with the Secretary of Health and Human Services shall be deemed to be a reopened claim for purposes of the ability of such hospital to resubmit a claim for payment under the appropriate provisions of such title XVIII and for purposes of requirements for the timely submission of claims by hospitals under such title XVIII, including under sections 1814(a), 1842(b)(3), and 1835(a) of the Social Security Act (42 U.S.C. 1395f(a), 1395u(b)(3), and 1395n(a), respectively). Such reopened claims are not subject to the timely filing limitations under such sections (and related regulations) and shall be adjusted and paid without regard to such timely filing limitations. In this paragraph, the term hospital has the meaning given such term in subsection

(e)of section 1861 of the Social Security Act ( 42 U.S.C. 1395x ), and includes a psychiatric hospital as defined in subsection

(f)of such section. The amendments made by paragraphs

(1)and (2), and the provisions of paragraph (3), shall take effect on the date of the enactment of this Act and apply to claims subject to audit on or after September 1, 2010.

Connectionstraces to 5

Traces to 5 documents

U.S. Code

2 references not yet in our index