‘‘(i) IN
GENERAL.—Except as pro-
vided in clause (ii), an administrative law
judge shall conduct and conclude a hearing
and render a decision on such hearing by
not later than the end of the 90-day period
beginning on the date a request for hear-
ing has been timely filed.
‘‘(ii) WAIVER OF DEADLINE BY PARTY
SEEKING
HEARING.—The 90-day period
under clause (i) shall not apply in the case
of a motion or stipulation by the party re-
questing the hearing to waive such period.
‘‘(D) DEPARTMENTAL APPEALS BOARD RE-
VIEW.—The Departmental Appeals Board of
the Department of Health and Human Services
shall conduct and conclude a review of the deci-
sion on a hearing described in subparagraph
(C) and make a decision or remand the case to
the administrative law judge for reconsideration
by not later than the end of the 90-day period
beginning on the date a request for review has
been timely filed.
‘‘(2) CONSEQUENCES
OF
FAILURE
TO
MEET
DEADLINES.—
‘‘(A) IN GENERAL.—(i) In the case of a
failure by a carrier to mail notice within the
time period described in subparagraphs (A) and
(B) of paragraph (1), the party requesting the
review or carrier hearing (as the case may be)
may request a hearing before an administrative
law judge, notwithstanding any requirements
for a carrier review or a carrier hearing for pur-
poses of the party’s right to a hearing before
such judge.
‘‘(ii) In the case of a failure by an admin-
istrative law judge to render a decision by the
end of the period described in paragraph
(1)(C), the party requesting the hearing may
request a review by the Departmental Appeals
Board, notwithstanding any requirements for a
hearing for purposes of the party’s right to
such a review.
‘‘(B) DAB HEARING PROCEDURE.—In the
case of a request described in subparagraph
(A)(ii), the Departmental Appeals Board shall
review the case de novo.’’.
(b) REVIEW OF NATIONAL AND LOCAL COVERAGE
DECISIONS.—
(1) IN GENERAL.—Section 1869(b)(3) of the
Social Security Act (42 U.S.C. 1395ff(b)(3)) is
amended to read as follows:
‘‘(3) Review of any coverage determination respecting
whether or not a particular type or class of items or serv-
ices is covered under this title shall be subject to the fol-
lowing limitations:
‘‘(A) In the case of any national coverage deter-
mination under section 1862(a)(1), the following
limitations apply:
‘‘(i) Such a determination shall not be re-
viewed by any administrative law judge.
‘‘(ii) Such a determination shall not be
held unlawful or set aside on the ground that
a requirement of section 553 of title 5, United
States Code, or section 1871(b), relating to
publication in the Federal Register or oppor-
tunity for public comment, was not satisfied.
‘‘(iii) Upon the filing of a complaint by an
aggrieved party, such a determination shall be
reviewed by the Departmental Appeals Board of
the Department of Health and Human Services.
In conducting such a review, the Departmental
Appeals Board shall review the record and shall
permit discovery and the taking of evidence to
evaluate the reasonableness of the determina-
tion. In reviewing such a determination, the De-
partmental Appeals Board shall defer only to
the reasonable findings of fact, reasonable in-
terpretations of law, and reasonable applica-
tions of fact to law by the Secretary.
‘‘(iv) A decision of the Departmental Ap-
peals Board constitutes a final agency action
and is subject to judicial review.
‘‘(B) In the case of a local coverage determina-
tion made by a fiscal intermediary or a carrier under
this title, the following limitations apply:
‘‘(i) Upon the filing of a complaint by an
aggrieved party, such a determination shall be
reviewed by an administrative law judge of the
Department of Health and Human Services.
The administrative law judge shall review the
record and shall permit discovery and the tak-
ing of evidence to evaluate the reasonableness
of the determination. In reviewing such a deter-
mination, the judge shall defer only to the rea-
sonable findings of fact, reasonable interpreta-
tions of law, and reasonable applications of fact
to law by the Secretary.
‘‘(ii) Such a determination may be re-
viewed by the Departmental Appeals Board of
the Department of Health and Human Services.
‘‘(iii) A decision of the Departmental Ap-
peals Board constitutes a final agency action
and is subject to judicial review.
‘‘(C) In the case of review of a determination
under subparagraph (A)(iii) or (B)(i) where the
moving party alleges that there are no material
issues of fact in dispute, and alleges that the only
issue is the constitutionality of a provision of this
title, or that a regulation, determination, or ruling
by the Secretary is invalid, the moving party may
seek review by a court of competent jurisdiction.’’.
(2) PENDING
NATIONAL
COVERAGE
DETER-
MINATIONS.—Section 1869(b) of such Act (42
U.S.C. 1395ff(b)) is amended by adding at the end
the following new paragraph:
‘‘(6)(A) In the event the Secretary has not issued a
national coverage or noncoverage determination with re-
spect to a particular type or class of items or services,
an affected party may submit to the Secretary a request
to make such a determination with respect to such items
or services. By not later than the end of the 90-day period
beginning on the date the Secretary receives such a re-
quest, the Secretary shall take one of the following actions:
‘‘(i) Issue a national coverage determination,
with or without limitations.
‘‘(ii) Issue a national noncoverage determina-
tion.
‘‘(iii) Issue a determination that no national
coverage or noncoverage determination is appro-
priate as of the end of such 90-day period with re-
spect to national coverage of such items or services.
‘‘(B) When issuing a determination under subpara-
graph (A), the Secretary shall include a explanation of the
basis for the determination. An action taken under sub-
paragraph (A) is deemed to be a national coverage deter-
mination for purposes of review under paragraph (3)(A).’’.
(c) STANDING.—Section 1869 of such Act (42 U.S.C.
1395ff), as amended in subsection (a), is further amended
by adding at the end the following new subsection:
‘‘(e) An action under this section may only be initi-
ated by an aggrieved person, or class of persons, with re-
spect to claims for rights to, or payments for, items and
services under this title, or coverage of items and services
under this title. Such a person, or class of persons, in-
cludes the following:
‘‘(1) Individuals entitled to benefits under part
A, or enrolled under part B, or both.
‘‘(2) Providers of services.
‘‘(3) Physicians.
‘‘(4) Other health care professionals entitled to
payment for services furnished under this title.
‘‘(5) Suppliers and manufacturers of items and
services covered, or seeking to be covered, under this
title.’’.
(d) ELIMINATION OF SUA SPONTE MOTIONS BY THE
SECRETARY
ON DECISIONS
OF
THE PROVIDER REIM-
BURSEMENT REVIEW BOARD.—Section 1878(f)(1) of such
Act (42 U.S.C. 1395oo(f)(1)) is amended—
(1) in the first sentence, by striking ‘‘unless the
Secretary, on his own motion, and within 60 days
after the provider of services is notified of the
Board’s decision, reverses, affirms, or modifies the
Board’s decision’’;
(2) in the second sentence, by striking ‘‘, or of
any reversal, affirmance, or modification by the Sec-
retary,’’ and ‘‘or of any reversal, affirmance, or
modification by the Secretary is received’’; and
(3) in the fifth sentence, by striking ‘‘ and not
subject to review by the Secretary’’.
(e) CONFORMING REGULATIONS.—
(1) IN GENERAL.—The Secretary of Health and
Human Services shall promptly publish notice of re-
visions in the process under section 1869 of the So-
cial Security Act (42 U.S.C. 1395ff), in order to re-
flect the modifications to such process made by this
section.
(2) REFERENCES.—For purposes of this section
and the notice published under paragraph (1), ref-
erence to—
(A) a reconsideration of an initial deter-
mination in subsection (c)(1)(A) of section
1869 of the Social Security Act (42 U.S.C.
1395ff), as added under subsection (a)(2), is a
reference to a reconsideration of an initial de-
termination under section 405.715 of title 42 of
the Code of Federal Regulations;
(B) the requirement to mail the notice of
reconsidered determination in such subsection,
as so added, is a reference to such requirement
under section 405.716 of such title;
(C) a hearing conducted by an administra-
tive law judge in subsection (c)(1)(B)(i) of such
section, as so added, is a reference to such a
hearing under section 405.720 of such title;
(D) review conducted by the Departmental
Appeals Board of the Department of Health
and Human Services in paragraphs (1)(C) and
(2)(A)(ii) of subsection (c) of such section
1869, as so added, is a reference to such review
conducted under section 405.724 of such title;
(E) a review of an initial determination in
subsection (d)(1)(A) of such section, as so
added, is a reference to such review conducted
under section 405.807 of such title;
(F) the requirement to mail the notice of
review determination in such subsection, as so
added, is a reference to such requirement under
section 405.811 of such title;
(G) a hearing in subsection (d)(1)(B)(i) of
such section, as so added, is a reference to such
a hearing under section 405.830 of such title;
(H) a hearing before an administrative law
judge in subparagraphs (B)(ii) and (C)(i) of
subsection (d)(1) of such section, as so added,
is a reference to such a hearing under section
405.855 of such title; and
(I) review conducted by the Departmental
Appeals Board of the Department of Health
and Human Services in paragraphs (1)(D) and
(2)(A)(ii) of subsection (d) of such section, as
so added, is a reference to such review con-
ducted under section 405.856 of such title.
(f) EFFECTIVE DATE.—This section, and the amend-
ments made by this section, apply as of the date that is
90 days after the date of the enactment of this Act, and
apply to reconsiderations, reviews, motions, and deter-
minations pending before, on, or after such date.
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