specific criteria and pediatric-specific criteria 
where available and appropriate. 
(B) CONTINUING USE OF STANDARDS IN 
RETROSPECTIVE
REVIEW.—If a health care 
service has been specifically pre-authorized or 
approved for a participant, beneficiary, or en-
rollee under such a program, the program shall 
not, pursuant to retrospective review, revise or 
modify the specific standards, criteria, or proce-
dures used for the utilization review for proce-
dures, treatment, and services delivered to the 
enrollee during the same course of treatment. 
(C) REVIEW OF SAMPLE OF CLAIMS DENI-
ALS.—Such a program shall provide for a peri-
odic evaluation of the clinical appropriateness of 
at least a sample of denials of claims for bene-
fits. 
(c) CONDUCT OF PROGRAM ACTIVITIES.— 
(1) ADMINISTRATION BY HEALTH CARE PRO-
FESSIONALS.—A utilization review program shall be 
administered by qualified health care professionals 
who shall oversee review decisions. 
(2) USE
OF
QUALIFIED, INDEPENDENT
PER-
SONNEL.—
(A) IN
GENERAL.—A utilization review 
program shall provide for the conduct of utiliza-
tion review activities only through personnel 
who are qualified and have received appropriate 
training in the conduct of such activities under 
the program. 
(B) PROHIBITION
OF
CONTINGENT
COM-
PENSATION ARRANGEMENTS.—Such a program 
shall not, with respect to utilization review ac-
tivities, permit or provide compensation or any-
thing of value to its employees, agents, or con-
tractors in a manner that encourages denials of 
claims for benefits. 
(C) PROHIBITION OF CONFLICTS.—Such a 
program shall not permit a health care profes-
sional who is providing health care services to 
an individual to perform utilization review ac-
tivities in connection with the health care serv-
ices being provided to the individual. 
(3) ACCESSIBILITY OF REVIEW.—Such a pro-
gram shall provide that appropriate personnel per-
forming utilization review activities under the pro-
gram, including the utilization review administrator, 
are reasonably accessible by toll-free telephone dur-
ing normal business hours to discuss patient care
and allow response to telephone requests, and that 
appropriate provision is made to receive and respond 
promptly to calls received during other hours. 
(4) LIMITS ON FREQUENCY.—Such a program 
shall not provide for the performance of utilization 
review activities with respect to a class of services 
furnished to an individual more frequently than is 
reasonably required to assess whether the services 
under review are medically necessary and appro-
priate. 
SEC. 102. PROCEDURES FOR INITIAL CLAIMS FOR BENE-
FITS AND PRIOR AUTHORIZATION DETER-
MINATIONS. 
(a) PROCEDURES OF INITIAL CLAIMS FOR BENE-
FITS.— 
(1) IN GENERAL.—A group health plan, and a 
health insurance issuer offering health insurance 
coverage, shall— 
(A) make a determination on an initial 
claim for benefits by a participant, beneficiary, 
or enrollee (or authorized representative) re-
garding payment or coverage for items or serv-
ices under the terms and conditions of the plan 
or coverage involved, including any cost-sharing 
amount that the participant, beneficiary, or en-
rollee is required to pay with respect to such 
claim for benefits; and 
(B) notify a participant, beneficiary, or en-
rollee (or authorized representative) and the 
treating health care professional involved re-
garding a determination on an initial claim for 
benefits made under the terms and conditions 
of the plan or coverage, including any cost-shar-
ing amounts that the participant, beneficiary, 
or enrollee may be required to make with re-
spect to such claim for benefits, and of the 
right of the participant, beneficiary, or enrollee 
to an internal appeal under section 103. 
(2) ACCESS TO INFORMATION.— 
(A) TIMELY PROVISION OF NECESSARY IN-
FORMATION.—With respect to an initial claim 
for benefits, the participant, beneficiary, or en-
rollee (or authorized representative) and the 
treating health care professional (if any) shall 
provide the plan or issuer with access to infor-
mation requested by the plan or issuer that is 
necessary to make a determination relating to 
the claim. Such access shall be provided not 
later than 5 days after the date on which the 
request for information is received, or, in a case