42 USC 1395 - Limitation on liability where claims are disallowed

Editorial Notes

Amendments

2014—Subsec. (i). Puspan. L. 113–185 added subsec. (i).

2011—Subsec. (a). Puspan. L. 112–40, § 261(a)(3)(A), substituted “quality improvement” for “utilization and quality control peer review” in concluding provisions.

Subsec. (e). Puspan. L. 112–40, § 261(a)(3)(B), substituted “quality improvement” for “quality control and peer review”.

1997—Subsec. (g). Puspan. L. 105–33 substituted “subsection is—” for “subsection is,”, redesignated remaining text as par. (1) and former pars. (1) and (2) as subpars. (A) and (B), respectively, of par. (1), realigned margins, substituted “; and” for period at end, and added par. (2).

1994—Subsec. (h). Puspan. L. 103–432 added subsec. (h).

1989—Subsec. (f)(1). Puspan. L. 101–239, § 6214(a)(1), struck out “with respect to any coverage denial described in subsection (g) of this section” before period at end.

Subsec. (f)(4). Puspan. L. 101–239, § 6214(a)(2), designated existing provisions as subpar. (A) and added subpar. (B).

Subsec. (f)(6). Puspan. L. 101–239, § 6214(span), added par. (6).

1987—Subsec. (span). Puspan. L. 100–203 struck out “, subject to the deductible and coinsurance provisions of this subchapter,” after “(referred to in such paragraphs)” and inserted at end “No item or service for which an individual is indemnified under this subsection shall be taken into account in applying any limitation on the amount of items and services for which payment may be made to or on behalf of the individual under this subchapter.”

1986—Subsec. (a). Puspan. L. 99–509, § 9305(g)(1)(A)–(C), inserted in par. (1) “or by reason of a coverage denial described in subsection (g)”, and in concluding provisions inserted “and as though the coverage denial described in subsection (g) had not occurred” and “or by reason of a coverage denial described in subsection (g)”.

Subsec. (c). Puspan. L. 99–509, § 9305(g)(1)(D), inserted “or by reason of a coverage denial described in subsection (g)”.

Subsec. (d). Puspan. L. 99–509, § 9341(a)(3), substituted “sections 1395ff(span) and 1395u(span)(3)(C) of this title (as may be applicable)” for “section 1395ff(span) of this title (when the determination is under part A) or section 1395u(span)(3)(C) of this title (when the determination is under part B)”.

Subsecs. (f), (g). Puspan. L. 99–509, § 9305(g)(1)(E), added subsecs. (f) and (g).

1982—Subsec. (a). Puspan. L. 97–248, § 145, inserted provisions relating to imputing knowledge to provider or other person furnishing items or services for which payment may not be made that payment may not be made if the provider or other person has been notified that a pattern of inappropriate utilization has occurred in the past and there has been a reasonable time for correction of such utilization.

Subsec. (e). Puspan. L. 97–248, § 148(e), substituted “quality control and peer review organization” for “professional standards review organization”.

1980—Subsec. (e). Puspan. L. 96–499 added subsec. (e).

Statutory Notes and Related Subsidiaries

Effective Date of 2011 Amendment

Amendment by Puspan. L. 112–40 applicable to contracts entered into or renewed on or after Jan. 1, 2012, see section 261(e) of Puspan. L. 112–40, set out as a note under section 1320c of this title.

Effective Date of 1997 Amendment

Amendment by Puspan. L. 105–33 applicable to benefits provided on or after Aug. 5, 1997, except as otherwise provided, see section 4449 of Puspan. L. 105–33, set out as a note under section 1395d of this title.

Effective Date of 1994 Amendment

Amendment by Puspan. L. 103–432 applicable to items or services furnished on or after Jan. 1, 1995, see section 133(c) of Puspan. L. 103–432, set out as a note under section 1395m of this title.

Effective Date of 1989 Amendment

Puspan. L. 101–239, title VI, § 6214(c), Dec. 19, 1989, 103 Stat. 2252, provided that: “The amendments made by subsection (a) [amending this section] shall apply to determinations for quarters beginning on or after the date of the enactment of this Act [Dec. 19, 1989].”

Effective Date of 1987 Amendment

Amendment by Puspan. L. 100–203 applicable to services furnished on or after Jan. 1, 1988, see section 4096(d) of Puspan. L. 100–203, set out as a note under section 1320c–3 of this title.

Effective Date of 1986 Amendment

Puspan. L. 99–509, title IX, § 9305(g)(3), Oct. 21, 1986, 100 Stat. 1993, as amended by Puspan. L. 100–360, title IV, § 426(c), July 1, 1988, 102 Stat. 814; Puspan. L. 101–508, title IV, § 4207(span)(3), formerly § 4027(span)(3), Nov. 5, 1990, 104 Stat. 1388–118, renumbered Puspan. L. 103–432, title I, § 160(d)(4), Oct. 31, 1994, 108 Stat. 4444, provided that: “The amendments made by paragraph (1) [amending this section] shall apply to coverage denials occurring on or after July 1, 1987, and before December 31, 1995.”

Amendment by section 9341(a)(3) of Puspan. L. 99–509 applicable to items and services furnished on or after Jan. 1, 1987, see section 9341(span) of Puspan. L. 99–509, set out as a note under section 1395ff of this title.

Effective Date of 1982 Amendment

Amendment by Puspan. L. 97–248 effective with respect to contracts entered into or renewed on or after Sept. 3, 1982, see section 149 of Puspan. L. 97–248, set out as an Effective Date note under section 1320c of this title.

Effective Date of 1980 Amendment

Puspan. L. 96–499, title IX, § 956(span), Dec. 5, 1980, 94 Stat. 2648, provided that: “The amendment made by subsection (a) [amending this section] shall take effect on January 1, 1981.”

Effective Date

Puspan. L. 92–603, title II, § 213(span), Oct. 30, 1972, 86 Stat. 1386, provided that: “The amendments made by this section [enacting this section] shall be effective with respect to claims under part A or part B of title XVIII of the Social Security Act [42 U.S.C. 1395c et seq., 1395j et seq.], filed with respect to items or services furnished after the date of the enactment of this Act [Oct. 30, 1972].”

Provisions Relating to Advance Beneficiary Notices; Report on Prior Determination Process

Puspan. L. 108–173, title IX, § 938(c), Dec. 8, 2003, 117 Stat. 2415, provided that:

“(1)Data collection.—The Secretary [of Health and Human Services] shall establish a process for the collection of information on the instances in which an advance beneficiary notice (as defined in paragraph (5)) has been provided and on instances in which a beneficiary indicates on such a notice that the beneficiary does not intend to seek to have the item or service that is the subject of the notice furnished.

“(2)Outreach and education.—The Secretary shall establish a program of outreach and education for beneficiaries and providers of services and other persons on the appropriate use of advance beneficiary notices and coverage policies under the medicare program.

“(3) GAO report on use of advance beneficiary notices.—Not later than 18 months after the date on which section 1869(h) of the Social Security Act [42 U.S.C. 1395ff(h)] (as added by subsection (a)) takes effect, the Comptroller General of the United States shall submit to Congress a report on the use of advance beneficiary notices under title XVIII of such Act [42 U.S.C. 1395 et seq.]. Such report shall include information concerning the providers of services and other persons that have provided such notices and the response of beneficiaries to such notices.

“(4) GAO report on use of prior determination process.—Not later than 36 months after the date on which section 1869(h) of the Social Security Act [42 U.S.C. 1395ff(h)] (as added by subsection (a)) takes effect, the Comptroller General of the United States shall submit to Congress a report on the use of the prior determination process under such section. Such report shall include—

“(A) information concerning—

“(i) the number and types of procedures for which a prior determination has been sought;

“(ii) determinations made under the process;

“(iii) the percentage of beneficiaries prevailing;

“(iv) in those cases in which the beneficiaries do not prevail, the reasons why such beneficiaries did not prevail; and

“(v) changes in receipt of services resulting from the application of such process;

“(B) an evaluation of whether the process was useful for physicians (and other suppliers) and beneficiaries, whether it was timely, and whether the amount of information required was burdensome to physicians and beneficiaries; and

“(C) recommendations for improvements or continuation of such process.

“(5)Advance beneficiary notice defined.—In this subsection, the term ‘advance beneficiary notice’ means a written notice provided under section 1879(a) of the Social Security Act (42 U.S.C. 1395pp(a)) to an individual entitled to benefits under part A or enrolled under part B of title XVIII of such Act [42 U.S.C. 1395c et seq., 1395j et seq.] before items or services are furnished under such part in cases where a provider of services or other person that would furnish the item or service believes that payment will not be made for some or all of such items or services under such title [42 U.S.C. 1395 et seq.].”

Reports to Congress on Denials of Bills for Payment

Puspan. L. 99–509, title IX, § 9305(g)(2), Oct. 21, 1986, 100 Stat. 1992, directed Secretary of Health and Human Services to report to Congress annually in March of 1987 and 1988 information on frequency and distribution (by type of provider) of denials of bills for payment under this subchapter for extended care services, home health services, and hospice care, by reason of section 1395y(a)(1) or (9) of this title, and coverage denials described in subsec. (g) of this section, and such other information as appropriate to evaluate the appropriateness of any percentage standards established for the granting of favorable presumptions with respect to such denials.