‘‘(i) EXCLUSIONS.—For purposes of 
this paragraph, a facsimile, a proprietary 
payer portal that does not meet standards 
specified by the Secretary, or an electronic 
form shall not be treated as an electronic 
transmission described in subparagraph 
(A). 
‘‘(ii) STANDARDS.— 
‘‘(I) IN GENERAL.—In order to 
ensure appropriate clinical outcome 
for individuals, for purposes of this 
paragraph, an electronic transmission 
described in subparagraph (A) shall 
comply 
with 
technical 
standards 
adopted by the Secretary in consulta-
tion with standard-setting organiza-
tions determined appropriate by the 
Secretary, health care professionals, 
MA organizations, and health infor-
mation technology software vendors. 
In adopting such standards, the Sec-
retary shall ensure that such trans-
missions support attachments con-
taining applicable clinical information 
and shall prioritize the adoption of 
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standards that encourage integration 
of the electronic prior authorization 
program into established electronic 
health record systems. 
‘‘(II) 
TRANSACTION
STAND-
ARD.—The Secretary shall include in 
the standards adopted under sub-
clause (I) a standard with respect to 
the transmission of attachments de-
scribed in such subclause, and data 
elements and operating rules for such 
transmission, consistent with health 
care industry standards. 
‘‘(C) REAL-TIME DECISIONS.— 
‘‘(i) IN GENERAL.—The program de-
scribed in subparagraph (A) shall provide 
for real-time decisions (as defined by the 
Secretary) with respect to requests identi-
fied by the Secretary pursuant to clause 
(ii) for a plan year if such requests contain 
all information required by an MA plan to 
evaluate the criteria described in para-
graph (4)(A)(iii)(II). 
‘‘(ii) 
IDENTIFICATION
OF
RE-
QUESTS.—For purposes of clause (i) and 
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with respect to a plan year, the Secretary 
shall identify, not later than the date on 
which the initial announcement described 
in section 1853(b)(1)(B)(i) for such plan 
year is required to be announced, items 
and services for which prior authorization 
requests are routinely approved. 
‘‘(iii) DATA
COLLECTION
AND
CON-
SULTATION
WITH
RELEVANT
ELIGIBLE 
PROFESSIONAL ORGANIZATIONS AND REL-
EVANT STAKEHOLDERS.—In identifying re-
quests for a year under clause (ii), the Sec-
retary shall use the information described 
in paragraph (4)(A) (if available) and shall 
issue a request for information from pro-
viders, suppliers, patient advocacy organi-
zations, and other stakeholders. 
‘‘(4) TRANSPARENCY REQUIREMENTS.— 
‘‘(A) IN GENERAL.—For purposes of para-
graph (1)(C), the transparency requirements 
specified in this paragraph are, with respect to 
a Medicare Advantage plan, the following: 
‘‘(i) The plan, not less frequently than 
annually and at a time and in a manner 
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specified by the Secretary, shall submit to 
the Secretary the following information: 
‘‘(I) A list of all items and serv-
ices that are described in subsection 
(a)(1)(B) that are subject to a prior 
authorization requirement under the 
plan. 
‘‘(II) The percentage of prior au-
thorization requests approved during 
the previous plan year by the plan 
with respect to each such item and 
service. 
‘‘(III) The percentage of such re-
quests that were initially denied and 
that were subsequently appealed, and 
the percentage of such appealed re-
quests that were overturned, with re-
spect to each such item and service. 
‘‘(IV) The average and the me-
dian amount of time (in hours) that 
elapsed during the previous plan year 
between the submission of such a re-
quest to the plan and a determination 
by the plan with respect to such re-
quest for each such item and service, 
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excluding any such requests that did 
not contain all information required to 
be submitted by the plan. 
‘‘(V) Such other information as 
the Secretary determines appropriate 
after consultation with and comment 
from stakeholders. 
‘‘(ii) The plan shall publish the infor-
mation described in clause (i) annually be-
fore open enrollment on a publicly available 
website. Such plan shall provide the ad-
dress of such website in any enrollment 
materials distributed by the plan and shall 
update such website in a timely manner. 
‘‘(iii) The plan shall provide— 
‘‘(I) along with contract mate-
rials for any provider or supplier who 
seeks to participate under the plan, 
the list described in clause (i)(I) and 
any policies or procedures used by the 
plan for making determinations with 
respect to prior authorization re-
quests; and 
‘‘(II) to each provider and sup-
plier participating under the plan, ac-
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cess to the criteria used by the plan 
for making such determinations, in-
cluding an itemization of the medical 
or other documentation required to be 
submitted by a provider or supplier 
with respect to such a request, except 
to the extent that provision of access 
to such criteria would disclose propri-
etary information of such plan, as de-
termined by the Secretary. 
‘‘(B) REPORT
TO
CONGRESS.—Not later 
than the end of the second plan year beginning 
on or after the date of the enactment of this 
subsection, and biennially thereafter, the Sec-
retary shall submit to Congress a report de-
scribing the information submitted under sub-
paragraph (A)(i) with respect to— 
‘‘(i) in the case of the first such re-
port, the first plan year beginning on or 
after such date; and 
‘‘(ii) in the case of a subsequent re-
port, the 2 full plan years preceding the 
date of the submission of such report. 
‘‘(5) BENEFICIARY PROTECTION STANDARDS.— 
The Secretary of Health and Human Services shall, 
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through notice and comment rulemaking, specify 
standards with respect to the use of prior authoriza-
tion by MA plans to ensure— 
‘‘(A) that such plans adopt transparent 
programs developed in consultation with pro-
viders and suppliers participating under the 
plans that promote the modification of such re-
quirements based on the performance of such 
providers and suppliers with respect to adher-
ence to evidence-based medical guidelines and 
other quality criteria; 
‘‘(B) that such plans conduct annual re-
views of items and services for which prior au-
thorization requirements are imposed under 
such plans through a process that takes into ac-
count input from participating providers and 
suppliers and is based on analysis of past prior 
authorization requests and current clinical cri-
teria; 
‘‘(C) continuity of care for individuals 
transitioning to, or between, coverage under 
such plans in order to minimize any disruption 
to ongoing treatment attributable to prior au-
thorization requirements under such plans; 
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‘‘(D) that such plans make timely prior au-
thorization determinations, provide rationales 
for denials, and ensure requests are reviewed by 
qualified medical personnel; and 
‘‘(E) that plans assist providers and sup-
pliers in submitting the information necessary 
to enable the plan to make a prior authorization 
determination in a timely manner.’’. 
(b) 
DETERMINATION
CLARIFICATION.—Section 
1852(g)(1)(A) of the Social Security Act (42 U.S.C. 
1392w–22(g)(1)(A)) is amended by inserting ‘‘(including 
any decision made with respect to a prior authorization 
request for such service)’’ after ‘‘section’’. 
Æ 
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