necessity review by the non-physician em-
ployee is appropriate; 
‘‘(ii) sign and certify such determina-
tion; and 
‘‘(iii) append such signed and certified 
determination to the claim file. 
‘‘(C) TREATMENT
AS
MEDICALLY
NEC-
ESSARY.—A claim with respect to which a de-
nial has been made as described in subpara-
graph (A) for which the physician determines 
the denial is not appropriate under subpara-
graph (B) shall be deemed to be medically nec-
essary. 
‘‘(D) MEDICAL
NECESSITY
REVIEW
DE-
FINED.—In this paragraph, the term ‘medical 
necessity review’ means, with respect to an 
audit of a claim of a provider of services or sup-
plier, 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 di-
agnosis or treatment of illness or injury under 
section 1862(a)(1)(A).’’. 
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(b) CONFORMING AMENDMENT TO MEDICARE AD-
MINISTRATIVE CONTRACTORS.—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 add-
ing at the end the following new paragraph: 
‘‘(5) PHYSICIAN VALIDATION OF MEDICAL NE-
CESSITY DENIALS MADE BY NON-PHYSICIAN REVIEW-
ERS.— 
‘‘(A) IN GENERAL.—A physician (as de-
fined in section 1861(r)(1)) shall review each 
denial of a claim for medical necessity when a 
medical necessity review of such claim is per-
formed and a denial is made by an employee of 
the contractor who is not a physician (as so de-
fined). 
‘‘(B) DETERMINATION; 
VALIDATION.—A 
physician reviewing a claim under subparagraph 
(A) shall— 
‘‘(i) make a determination whether 
the denial of the claim under the medical 
necessity review by the non-physician em-
ployee is appropriate; 
‘‘(ii) sign and certify such determina-
tion; and 
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‘‘(iii) append such signed and certified 
determination to the claim file. 
‘‘(C) TREATMENT
AS
MEDICALLY
NEC-
ESSARY.—A claim with respect to which a de-
nial has been made as described in subpara-
graph (A) for which the physician determines 
the denial is not appropriate under subpara-
graph (B) shall be deemed to be medically nec-
essary. 
‘‘(D) MEDICAL
NECESSITY
REVIEW
DE-
FINED.—In this paragraph, the term ‘medical 
necessity review’ means, with respect to an 
audit of a claim of a provider of services or sup-
plier, a review conducted by a medicare admin-
istrative contractor for the purpose of deter-
mining 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 in-
jury under section 1862(a)(1)(A).’’. 
(c) CONFORMING REQUIREMENT FOR CERT CON-
TRACTORS.— 
(1) CONTRACT REQUIREMENT FOR PHYSICIAN 
VALIDATION OF MEDICAL NECESSITY DENIALS MADE 
BY NON-PHYSICIAN REVIEWERS.—The Secretary of 
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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). 
(2) DETERMINATION; VALIDATION.—A physi-
cian reviewing a claim under paragraph (1) shall— 
(A) make a determination whether the de-
nial of the claim under the medical necessity re-
view by the non-physician employee is appro-
priate; 
(B) sign and certify such determination; 
and 
(C) append such signed and certified deter-
mination to the claim file. 
(3) TREATMENT AS MEDICALLY NECESSARY.— 
A claim with respect to which a denial has been 
made as described in paragraph (1) for which the 
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physician determines the denial is not appropriate 
under paragraph (2) shall be deemed to be medically 
necessary. 
(4) MEDICAL NECESSITY REVIEW DEFINED.— 
In this subsection, the term ‘‘medical necessity re-
view’’ 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 diag-
nosis 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)). 
(d) EFFECTIVE DATE.—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 ad-
ministrative contractors under section 1874A of the Social 
Security Act (42 U.S.C. 1395kk–1) and Comprehensive 
Error Rate Testing (CERT) program contractors, respec-
tively, on or after the date of the enactment of this Act. 
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