The Secretary shall develop guidelines for the structure
and requirements applicable to the independent review
panel and impartial arbitration process described in para-
graph (2).
(d) WRITTEN DECISION.—With respect to the com-
plaint, grievance, and appeals processes required under
this section, the organization shall, upon the request of
an enrollee, provide the enrollee a written decision con-
cerning a complaint, grievance, or appeal in a timely man-
ner consistent with subsections (c)(3) and (f).
(e) CONSTRUCTION.—The complaint, grievance, and
appeals processes established in accordance with this sec-
tion may not be used in any fashion to discourage or pre-
vent an enrollee from receiving medically necessary care
in a timely manner.
(f) PROMPT RESPONSE TO REQUESTS FOR SERV-
ICES.—In addition to the procedures available pursuant
to the previous provisions of this section, in the case of
the request of an enrollee with a managed care organiza-
tion—
(1) the organization shall respond to the re-
quest not later than 24 hours after the request is
made; and
(2) the organization shall hear and resolve the
enrollee’s appeal of a denial of coverage of such serv-
ices in accordance with a process meeting standards
established by the Secretary.
SEC. 10. DUE PROCESS FOR HEALTH CARE PROFESSIONALS
AND PROVIDERS.
(a) IN GENERAL.—A managed care organization
shall—
(1) allow all health care professionals and pro-
viders in its service area to apply to become a par-
ticipating health care professional or provider during
at least one period in each calendar year;
(2) provide reasonable notice to such health
care professionals and providers of the opportunity
to apply and of the period during which applications
are accepted;
(3) provide for review of each application by a
credentialing committee with appropriate representa-
tion of the category or type of health care profes-
sional or provider;
(4) select participating health care professionals
and providers based on objective standards of qual-
ity developed with the suggestions and advice of pro-
fessional associations, health care professionals, and
providers;
(5) make such selection standards available
to—
(A) those applying to become a participat-
ing provider or health care professional,
(B) health plan purchasers, and
(C) enrollees;
(6) when economic considerations are taken
into account in selecting participating health care
professionals and providers, use objective criteria
that are available to those applying to become a par-
ticipating provider or health care professional and
enrollees;
(7) adjust any economic profiling to take into
account patient characteristics (such as severity of
illness) that may result in atypical utilization of
services;
(8) make the results of such profiling available
to insurance purchasers, enrollees, and the health
care professional or provider involved;
(9) notify any health care professional or pro-
vider being reviewed under the process referred to in
paragraph (3) of any information indicating that the
health care professional or provider fails to meet the
standards of the organization;
(10) offer a health care professional or provider
receiving notice pursuant to the requirement of
paragraph (9) with an opportunity to—
(A) review the information referred to in
such paragraph, and
(B) submit supplemental or corrected in-
formation;
(11) not include in its contracts with participat-
ing health care professionals and providers a provi-
sion permitting the organization to terminate the
contract ‘‘without cause’’;
(12) provide a due process appeal that con-
forms to the process specified in section 412 of the
Health Care Quality Improvement Act of 1986 (42
U.S.C. 11112) for all determinations that are ad-
verse to a health care professional or provider; and
(13) unless a health care professional or pro-
vider poses an imminent harm to enrollees or an ad-
verse action by a governmental agency effectively im-
pairs the ability to provide health care items and
services, provide—
(A) reasonable notice of any decision to
terminate a health care professional or provider
‘‘for cause’’ (including an explanation of the
reasons for the determination),
(B) an opportunity to review and discuss
all of the information on which the determina-
tion is based, and
(C) an opportunity to enter into a correc-
tive action plan, before the determination be-
comes subject to appeal under the process re-
ferred to in paragraph (12).
(b) 
LIMITATION
ON
USE
OF
NON-COMPETE
CLAUSES.—A managed care organization may not (di-
rectly or indirectly) seek to enforce any contractual provi-
sion which prevents a health care professional or provider
whose contractual obligations to the organization for the
provision of services through the organization have ended
from joining or forming any competing managed care or-
ganization, whether or not the organization serves the
same geographic area.
(c) EQUAL COMPENSATION ARRANGEMENTS.—
(1) IN GENERAL.—Subject to paragraph (2), a
managed care organization shall provide for com-
parable payment for all health care professionals and
providers in the same field or specialty located in
the same geographic area.
(2) ADJUSTMENTS AUTHORIZED.—A managed
care organization may adjust the amount of com-
pensation among professionals and providers for ex-
perience and other relevant factors, including bonus
payments that reflect quality factors, such as en-
rollee satisfaction and medical chart reviews, unless
such payments are based solely on cost-effectiveness
of services provided.
(d) RULE OF CONSTRUCTION.—The requirements of
subsection (a) shall not be construed as preempting or su-
perseding any other reviews and appeals a managed care
organization is required by law to make available.
SEC. 11. REQUIREMENTS FOR QUALITY IMPROVEMENT
PROGRAM AND UTILIZATION REVIEW PRO-
GRAMS.
(a) QUALITY IMPROVEMENT PROGRAM.—
(1) IN GENERAL.—A managed care organiza-
tion shall establish a quality improvement program
(consistent with paragraph (2)) that systematically
and continuously assesses and improves—
(A) enrollee health status, patient out-
comes, processes of care, and enrollee satisfac-
tion associated with health care provided by the
organization; and
(B) the administrative and funding capac-
ity of the organization to support and empha-
size preventive care, utilization, access and
availability, cost effectiveness, acceptable treat-
ment modalities, specialists referrals, the peer
review process, and the efficiency of the admin-
istrative process.