2014—Subsec. (f)(2)(C). Pub. L. 113–93 added subpar. (C).
2011—Subsec. (a)(1)(C). Pub. L. 112–40, § 261(a)(3)(A), substituted “quality improvement” for “utilization and quality control peer review”.
Subsec. (c)(3)(G). Pub. L. 112–40, § 261(a)(3)(F), substituted “quality improvement organizations” for “peer review organizations”.
2003—Subsec. (a)(3)(C)(ii). Pub. L. 108–173, § 940(a)(1), substituted “60-day period” for “30-day period” in two places.
Subsec. (a)(4), (5). Pub. L. 108–173, § 933(c)(1), added pars. (4) and (5).
Subsec. (b)(1)(A). Pub. L. 108–173, § 932(a)(1)(A), inserted “, subject to paragraph (2),” before “to judicial review of the Secretary’s final decision”.
Subsec. (b)(1)(E)(iii). Pub. L. 108–173, § 940(b)(1), added cl. (iii).
Subsec. (b)(1)(F)(ii). Pub. L. 108–173, § 932(a)(2), amended heading and text of cl. (ii) generally. Prior to amendment, text read as follows: “In a hearing by the Secretary under this section, in which the moving party alleges that no material issues of fact are in dispute, the Secretary shall make an expedited determination as to whether any such facts are in dispute and, if not, shall render a decision expeditiously.”
Subsec. (b)(2). Pub. L. 108–173, § 932(a)(1)(B), added par. (2).
Subsec. (b)(3). Pub. L. 108–173, § 933(a)(1), added par. (3).
Subsec. (c)(3)(A). Pub. L. 108–173, § 933(d)(1)(A), substituted “sufficient medical, legal, and other expertise (including knowledge of the program under this subchapter) and sufficient staffing” for “sufficient training and expertise in medical science and legal matters”.
Subsec. (c)(3)(B)(i). Pub. L. 108–173, § 933(b), inserted “(including the medical records of the individual involved)” after “clinical experience”.
Subsec. (c)(3)(C)(i). Pub. L. 108–173, § 940(a)(2), substituted “60-day period” for “30-day period”.
Subsec. (c)(3)(D). Pub. L. 108–173, § 933(d)(2)(A), amended heading and text of subpar. (D) generally, substituting provisions directing that subsec. (g) requirements be met for provisions prohibiting a physician or health care professional from reviewing a determination where such physician or health care professional had been directly responsible for furnishing services or had had a significant financial interest in the institution, organization, or agency which provided the services.
Subsec. (c)(3)(E). Pub. L. 108–173, § 933(c)(2), inserted “be written in a manner calculated to be understood by the individual entitled to benefits under part A or enrolled under part B, or both, and shall include (to the extent appropriate)” after “in writing,” and “and a notification of the right to appeal such determination and instructions on how to initiate such appeal under this section” after “such decision,”.
Subsec. (c)(3)(I)(ii)(III). Pub. L. 108–173, § 948(b)(1)(A), substituted “determination” for “policy”.
Subsec. (c)(3)(I)(ii)(IV). Pub. L. 108–173, § 948(b)(1)(B), substituted “coverage determinations” for “medical review policies”.
Subsec. (c)(3)(J)(i). Pub. L. 108–173, § 933(c)(4), substituted “submit” for “prepare” and struck out “with respect to a reconsideration to the Secretary for a hearing, including as necessary, explanations of issues involved in the decision and relevant policies” after “decision of the contractor”.
Subsec. (c)(3)(K). Pub. L. 108–173, § 933(d)(1)(B), added subpar. (K).
Subsec. (c)(4). Pub. L. 108–173, § 933(d)(3), substituted “a sufficient number of qualified independent contractors (but not fewer than 4 such contractors) to conduct reconsiderations consistent with the timeframes applicable under this subsection” for “not fewer than 12 qualified independent contractors under this subsection”.
Subsec. (d). Pub. L. 108–173, § 933(c)(3)(A), inserted “; notice” after “Secretary” in heading.
Subsec. (d)(4). Pub. L. 108–173, § 933(c)(3)(B), added par. (4).
Subsec. (f)(2)(A)(i). Pub. L. 108–173, § 931(d), struck out “of the Social Security Administration” after “an administrative law judge” in introductory provisions.
Subsec. (f)(4)(A)(iv). Pub. L. 108–173, § 948(c)(1), substituted “clause (i), (ii), or (iii)” for “subclause (I), (II), or (III)”.
Subsec. (f)(4)(B). Pub. L. 108–173, § 948(c)(2), substituted “subparagraph (A)(iv)” for “clause (i)(IV)” and “subparagraph (A)(iii)” for “clause (i)(III)”.
Subsec. (f)(4)(C). Pub. L. 108–173, § 948(c)(3), substituted “subparagraph (A)” for “clause (i)” in two places, “clause (iv)” for “subclause (IV)”, and “paragraph (1)(A)” for “subparagraph (A)”.
Subsec. (g). Pub. L. 108–173, § 933(d)(2)(B), added subsec. (g).
Subsec. (h). Pub. L. 108–173, § 938(a), added subsec. (h).
Subsec. (i). Pub. L. 108–173, § 940A(a), added subsec. (i).
2000—Pub. L. 106–554, § 1(a)(6) [title V, § 521(a)], amended section generally, completely revising and expanding provisions relating to determinations with respect to benefits under part A or part B of this subchapter, changing the structure of the section from two subsecs. lettered (a) and (b) to five subsecs. lettered (a) to (e).
Subsec. (f). Pub. L. 106–554, § 1(a)(6) [title V, § 522(a)], added subsec. (f).
1997—Subsec. (b)(2)(B). Pub. L. 105–33 inserted “(or $100 in the case of home health services)” after “$500”.
1994—Subsec. (b)(1). Pub. L. 103–296 inserted “, except that, in so applying such sections and in applying section 405(l) of this title thereto, any reference therein to the Commissioner of Social Security or the Social Security Administration shall be considered a reference to the Secretary or the Department of Health and Human Services, respectively” after “section 405(g) of this title” in closing provisions.
1987—Subsec. (a). Pub. L. 100–203, § 4085(i)(18), inserted “or a claim for benefits with respect to home health services under part B of this subchapter” before “shall”.
Subsec. (b)(2). Pub. L. 100–203, § 4085(i)(19), inserted “and (1)(D)” after “paragraph (1)(C)” in two places.
Subsec. (b)(3)(B). Pub. L. 100–203, § 4082(a), substituted “section 553” for “chapter 5”.
Subsec. (b)(5). Pub. L. 100–203, § 4082(b), added par. (5).
Subsec. (c). Pub. L. 100–93 struck out subsec. (c) which read as follows: “Any institution or agency dissatisfied with any determination by the Secretary that it is not a provider of services, or with any determination described in section 1395cc(b)(2) of this title, shall be entitled to a hearing thereon by the Secretary (after reasonable notice and opportunity for hearing) to the same extent as is provided in section 405(b) of this title, and to judicial review of the Secretary’s final decision after such hearing as is provided in section 405(g) of this title.”
1986—Subsec. (a). Pub. L. 99–509, § 9341(a)(1)(A), inserted “or part B” after “amount of benefits under part A”.
Pub. L. 99–509, § 9313(b)(1)(A), inserted “and any other determination with respect to a claim for benefits under part A of this subchapter” before “shall”.
Subsec. (b)(1). Pub. L. 99–509, § 9313(a)(1), in concluding provisions, inserted at end “Sections 406(a), 1302, and 1395hh of this title shall not be construed as authorizing the Secretary to prohibit an individual from being represented under this subsection by a person that furnishes or supplies the individual, directly or indirectly, with services or items solely on the basis that the person furnishes or supplies the individual with such a service or item. Any person that furnishes services or items to an individual may not represent an individual under this subsection with respect to the issue described in section 1395pp(a)(2) of this title unless the person has waived any rights for payment from the beneficiary with respect to the services or items involved in the appeal. If a person furnishes services or items to an individual and represents the individual under this subsection, the person may not impose any financial liability on such individual in connection with such representation.”
Subsec. (b)(1)(C). Pub. L. 99–509, § 9341(a)(1)(B), inserted “or part B”.
Subsec. (b)(1)(D). Pub. L. 99–509, § 9313(b)(1)(B), added subpar. (D).
Subsec. (b)(2). Pub. L. 99–509, § 9341(a)(1)(C), amended par. (2) generally. Prior to amendment, par. (2) read as follows: “Notwithstanding the provisions of subparagraph (C) of paragraph (1) of this subsection, a hearing shall not be available to an individual by reason of such subparagraph (C) if the amount in controversy is less than $100; nor shall judicial review be available to an individual by reason of such subparagraph (C) if the amount in controversy is less than $1,000.”
Subsec. (b)(3), (4). Pub. L. 99–509, § 9341(a)(1)(D), added pars. (3) and (4).
1984—Subsec. (b)(1)(B). Pub. L. 98–369 struck out the comma before “or section 1395i–2” and struck out “, or section 1819” after “section 1395i–2 of this title”.
1972—Subsec. (b). Pub. L. 92–603 redesignated existing provisions as par. (1), generally amended conditions under which a dissatisfied individual shall be entitled to a hearing by Secretary and to judicial review of final decision of Secretary after such hearing, and added par. (2).
References to Medicare+Choice deemed to refer to Medicare Advantage or MA, subject to an appropriate transition provided by the Secretary of Health and Human Services in the use of those terms, see section 201 of Pub. L. 108–173, set out as a note under section 1395w–21 of this title.
Amendment by Pub. L. 112–40 applicable to contracts entered into or renewed on or after
Amendment by section 932(a) of Pub. L. 108–173 applicable to appeals filed on or after
Pub. L. 108–173, title IX, § 933(a)(2),
Pub. L. 108–173, title IX, § 933(d)(4),
Pub. L. 108–173, title IX, § 938(b), “(1) The Secretary [of Health and Human Services] shall establish the prior determination process under the amendment made by subsection (a) [amending this section] in such a manner as to provide for the acceptance of requests for determinations under such process filed not later than 18 months after the date of the enactment of this Act [“(2) Such prior determination process shall not apply to requests filed after the end of the 5-year period beginning on the first date on which requests for determinations under such process are accepted.“(3) During the period in which the amendment made by subsection (a) [amending this section] has become effective but contracts are not provided under section 1874A of the Social Security Act [42 U.S.C. 1395kk–1] with medicare administrative contractors, any reference in section 1869(g) [probably should be 1869(h)] of such Act [42 U.S.C. 1395ff(h)] (as added by such amendment) to such a contractor is deemed a reference to a fiscal intermediary or carrier with an agreement under section 1816, or contract under section 1842, respectively, of such Act [42 U.S.C. 1395h, 1395u].“(4) For purposes of applying section 1848(f)(2)(D) of the Social Security Act (42 U.S.C. 1395w–4(f)(2)(D)), the amendment made by subsection (a) [amending this section] shall not be considered to be a change in law or regulation.”
Amendment by section 948(b)(1), (c) of Pub. L. 108–173 effective, except as otherwise provided, as if included in the enactment of BIPA [the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, H.R. 5661, as enacted by section 1(a)(6) of Public Law 106–554], see section 948(e) of Pub. L. 108–173, set out as a note under section 1314 of this title.
Amendment by section § 1(a)(6) [title V, § 521(a)] of Pub. L. 106–554 applicable with respect to initial determinations made on or after
Amendment by section 1(a)(6) [title V, § 522(a)] of Pub. L. 106–554 applicable with respect to a review of any national or local coverage determination filed, a request to make such a determination made, and a national coverage determination made, on or after
Amendment by Pub. L. 105–33 applicable to services furnished on or after
Amendment by Pub. L. 103–296 effective
Pub. L. 100–203, title IV, § 4082(e)(1), (2), “(1) The amendment made by subsection (a) [amending this section] shall take effect on the date of the enactment of this Act [“(2) The amendment made by subsection (b) [amending this section] shall apply to requests for hearings filed after the end of the 60-day period beginning on the date of the enactment of this Act.”
Amendment by Pub. L. 100–93 effective at end of fourteen-day period beginning
Pub. L. 99–509, title IX, § 9313(b)(2),
Pub. L. 99–509, title IX, § 9341(b),
Amendment by Pub. L. 98–369 effective
Pub. L. 92–603, title II, § 299O(b), “(1) The provisions of subparagraphs (A) and (B) of section 1869(b)(1) of the Social Security Act [42 U.S.C. 1395ff(b)(1)(A), (B)], as amended by subsection (a) of this section, shall be effective on the date of enactment of this Act [“(2) The provisions of paragraph (2) and subparagraph (C) of paragraph (1) of section 1869(b) of the Social Security Act [42 U.S.C. 1395ff(b)(2), (b)(1)(C)], as amended by subsection (a) of this section, shall be effective with respect to any claims under part A of title XVIII of such Act [42 U.S.C. 1395c et seq.], filed—“(A) in or after the month in which this Act is enacted [Oct. 1972], or“(B) before the month in which this Act is enacted [Oct. 1972], but only if a civil action with respect to a final decision of the Secretary of Health, Education, and Welfare on such claim has not been commenced under such section 1869(b) [42 U.S.C. 1395ff(b)] before such month.”
Pub. L. 108–173, title IX, § 931(a)–(c), “(a) “(1) Not later than “(2) The plan shall include information on the following:“(A) The number of such administrative law judges and support staff required now and in the future to hear and decide such cases in a timely manner, taking into account the current and anticipated claims volume, appeals, number of beneficiaries, and statutory changes.“(B) Funding levels required for fiscal year 2005 and subsequent fiscal years to carry out the functions transferred under the plan.“(C) A timetable for the transition.“(D) The establishment of specific regulations to govern the appeals process.“(E) The development of a unified case tracking system that will facilitate the maintenance and transfer of case specific data across both the fee-for-service and managed care components of the medicare program.“(F) The feasibility of developing a process to give decisions of the Departmental Appeals Board in the Department of Health and Human Services addressing broad legal issues binding, precedential authority.“(G) The feasibility of—“(i) filing appeals with administrative law judges electronically; and“(ii) conducting hearings using tele- or video-conference technologies.“(H) The steps that should be taken to ensure the independence of administrative law judges consistent with the requirements of subsection (b)(2).“(I) The steps that should be taken to provide for an appropriate geographic distribution of administrative law judges throughout the United States to carry out subsection (b)(3).“(J) The steps that should be taken to hire administrative law judges (and support staff) to carry out subsection (b)(4).“(K) The appropriateness of establishing performance standards for administrative law judges with respect to timelines for decisions in cases under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] taking into account requirements under subsection (b)(2) for the independence of such judges and consistent with the applicable provisions of title 5, United States Code[,] relating to impartiality.“(L) The steps that should be taken to carry out subsection (b)(6) (relating to the arrangements with the Commissioner of Social Security to share office space, support staff, and other resources, with appropriate reimbursement).“(M) The training that should be provided to administrative law judges with respect to laws and regulations under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.].“(3) The plan may also include recommendations for further congressional action, including modifications to the requirements and deadlines established under section 1869 of the Social Security Act (42 U.S.C. 1395ff) (as amended by this Act).“(4) GAO The Comptroller General of the United States shall evaluate the plan and, not later than the date that is 6 months after the date on which the plan is received by the Comptroller General, shall submit to Congress a report on such evaluation.“(b) “(1) Not earlier than “(2) The Secretary shall assure the independence of administrative law judges performing the administrative law judge functions transferred under paragraph (1) from the Centers for Medicare & Medicaid Services and its contractors. In order to assure such independence, the Secretary shall place such judges in an administrative office that is organizationally and functionally separate from such Centers. Such judges shall report to, and be under the general supervision of, the Secretary, but shall not report to, or be subject to supervision by, another officer of the Department of Health and Human Services.“(3) The Secretary shall provide for an appropriate geographic distribution of administrative law judges performing the administrative law judge functions transferred under paragraph (1) throughout the United States to ensure timely access to such judges.“(4) Subject to the amounts provided in advance in appropriations Acts, the Secretary shall have authority to hire administrative law judges to hear such cases, taking into consideration those judges with expertise in handling medicare appeals and in a manner consistent with paragraph (3), and to hire support staff for such judges.“(5) Amounts payable under law to the Commissioner for administrative law judges performing the administrative law judge functions transferred under paragraph (1) from the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund shall become payable to the Secretary for the functions so transferred.“(6) The Secretary shall enter into such arrangements with the Commissioner as may be appropriate with respect to transferred functions of administrative law judges to share office space, support staff, and other resources, with appropriate reimbursement from the Trust Funds described in paragraph (5).“(c) In addition to any amounts otherwise appropriated, to ensure timely action on appeals before administrative law judges and the Departmental Appeals Board consistent with section 1869 of the Social Security Act (42 U.S.C. 1395ff) (as amended by this Act), there are authorized to be appropriated (in appropriate part from the Federal Hospital Insurance Trust Fund, established under section 1817 of the Social Security Act (42 U.S.C. 1395i), and the Federal Supplementary Medical Insurance Trust Fund, established under section 1841 of such Act (42 U.S.C. 1395t)) to the Secretary such sums as are necessary for fiscal year 2005 and each subsequent fiscal year to—“(1) increase the number of administrative law judges (and their staffs) under subsection (b)(4);“(2) improve education and training opportunities for administrative law judges (and their staffs); and“(3) increase the staff of the Departmental Appeals Board.”
Pub. L. 108–173, title IX, § 933(d)(5),
Pub. L. 108–173, title IX, § 937, “(a) The Secretary [of Health and Human Services] shall develop, in consultation with appropriate medicare contractors (as defined in section 1889(g) of the Social Security Act [42 U.S.C. 1395zz(g)], as inserted by section 301(a)(1) [probably should be 921(f)(1)]) and representatives of providers of services and suppliers, a process whereby, in the case of minor errors or omissions (as defined by the Secretary) that are detected in the submission of claims under the programs under title XVIII of such Act [42 U.S.C. 1395 et seq.], a provider of services or supplier is given an opportunity to correct such an error or omission without the need to initiate an appeal. Such process shall include the ability to resubmit corrected claims.“(b) Not later than 1 year after the date of the enactment of this Act [
Pub. L. 101–508, title IV, § 4113,
Pub. L. 100–203, title IV, § 4037, “(a) Any hearing conducted under section 1869(b)(1) of the Social Security Act [42 U.S.C. 1395ff(b)(1)] prior to the earliest of the date on which the Secretary of Health and Human Services submits the report required to be submitted by the Secretary under subsection (b)(1) or September 1 shall be conducted by Administrative Law Judges of the Office of Hearings and Appeals of the Social Security Administration in the same manner as are hearings conducted under section 205(b)(1) of such Act [42 U.S.C. 405(b)(1)].“(b) “(1) The Secretary of Health and Human Services and the Comptroller General of the United States shall each conduct a study on holding hearings under section 1869(b)(1) of the Social Security Act [42 U.S.C. 1395ff(b)(1)] by telephone and shall each report the results of the study not later than 6 months after the date of enactment of this Act [“(2) The studies under paragraph (1) shall focus on whether telephone hearings allow for a full and fair evidentiary hearing, in general, or with respect to any particular category of claims and shall examine the possible improvements to the hearing process (such as cost-effectiveness, convenience to the claimant, and reduction in time under the process) resulting from the use of such hearings as compared to the adoption of other changes to the process (such as expansions in staff and resources).”