date that is 6 months after the date standards are
established under subsection (c).
(b) ENFORCEMENT THROUGH CIVIL MONEY PEN-
ALTIES.—
(1) IN GENERAL.—
(A) PROVIDERS.—In the case of a health
service provider that submits a claim in viola-
tion of subsection (a)(1), the provider is subject
to a civil money penalty of not to exceed $100
(or, if greater, the amount of the claim) for
each such violation.rejects a claim in violation
of subsection (a)(2), the plan is subject to a
civil money penalty of not to exceed $100 (or,
if greater, the amount of the claim) for each
such violation.
(B) PLANS.—In the case of a health bene-
fit plan that rejects a claim in violation of sub-
section (a)(2), the plan is subject to a civil
monetary penalty of not to exceed $100 (or, if
greater, the amount of the claim) for each such
violation.
(2) PROCESS.—The provisions of section 1128A
of the Social Security Act (other than subsections
(a) and (b)) shall apply to a civil money penalty
under paragraph (1) in the same manner as such
provisions apply to a penalty or proceeding under
section 1128A(a) of such Act.
(3) SUNSET
FOR
PENALTY.—No civil money
penalty may be imposed under this subsection for
submission (or rejection) of any claim on or after
the date that is 36 months after the effective date
specified in subsection (a)(3).
(c) STANDARDS RELATING TO UNIFORM CLAIMS.—
(1) ESTABLISHMENT
OF
STANDARDS.—The
Secretary of Health and Human Services shall es-
tablish standards that relate to the form and man-
ner of submission of claims for benefits under a
health benefit plan.
(2) SCOPE OF INFORMATION.—
(A) IN
GENERAL.—The standards under
this subsection are intended to cover substan-
tially most claims that are filed under health
benefit plans. Such information need not in-
clude all elements that may potentially be re-
quired to be reported under utilization review
provisions of plans.
(B) 
ENSURING
ACCOUNTABILITY
FOR
CLAIMS SUBMITTED ELECTRONICALLY.—In es-
tablishing such standards, the Secretary, in
consultation with appropriate agencies, shall in-
clude such methods of ensuring provider re-
sponsibility and accountability for claims sub-
mitted electronically that are designed to con-
trol fraud and abuse in the submission of such
claims.
(C) COMPONENTS.—In establishing such
standards the Secretary shall—
(i) with respect to data elements, de-
fine data fields, formats, and medical no-
menclature, and plan benefit and insurance
information; and
(ii) develop a single, uniform coding
system for diagnostic and procedure codes.
(3) USE OF TASK FORCES.—In adopting stand-
ards under this subsection, the Secretary shall take
into account the recommendations of current task
forces, including at least the Workgroup on Elec-
tronic Data Interchange, National Uniform Billing
Committee, the Uniform Claim Task Force, and the
Computer-based Patient Record Institute.
(4) UNIFORM, UNIQUE PROVIDER IDENTIFICA-
TION CODES.—In establishing standards under this
subsection—
(A) the Secretary shall provide for a
unique identifier code for each health service
provider that furnishes services for which a
claim may be submitted under a health benefit
plan, and
(B) in the case of a provider that has a
unique identifier issued for purposes of the
medicare program, the code provided under
subparagraph (A) shall be the same as such
unique identifier.
(5) DEADLINE.—The Secretary shall first pro-
vide for the standards for the uniform claims under
this subsection by not later than 1 year after the
date of the enactment of this Act.
(d) USE UNDER MEDICARE AND MEDICAID PRO-
GRAMS.—
(1) REQUIREMENT
FOR
PROVIDERS.—In the
case of a health service provider that submits a
claim for services furnished under the medicare pro-
gram or medicaid program in violation of subsection
(a)(1), no payment shall be made under such pro-
gram for such services.
(2) REQUIREMENTS OF INTERMEDIARIES AND
CARRIERS UNDER MEDICARE PROGRAM.—The Sec-
retary shall provide, in regulations promulgated to
carry out title XVIII of the Social Security Act, that
the claims process provided under that title is modi-
fied to the extent required to conform to the stand-
ards established under subsection (c).
(3) 
REQUIREMENTS
OF
STATE
MEDICAID
PLANS.—As a condition for the approval of State
plans under the medicaid program, effective as of
the effective date specified in subsection (a)(3), each
such plan shall provide, in accordance with regula-
tions of the Secretary, that the claims process pro-
vided under the plan is modified to the extent re-
quired to conform to the standards established under
subsection (c).
(e) DEFINITIONS.—
(1) HEALTH BENEFIT PLAN.—In this section:
(A) IN GENERAL.—The term ‘‘health bene-
fit plan’’ means, except as provided in subpara-
graphs (B) through (D), any public or private
entity or program that provides for payments
for health care services, including—
(i) a group health plan (as defined in
section 5000(b)(1) of the Internal Revenue
Code of 1986), and
(ii) any other health insurance ar-
rangement, including any arrangement
consisting of a hospital or medical expense
incurred policy or certificate, hospital or
medical service plan contract, or health
maintenance organization subscriber con-
tract.
(B) PLANS EXCLUDED.—Such term does
not include—
(i) accident-only, credit, or disability
income insurance;
(ii) coverage issued as a supplement
to liability insurance;
(iii) an individual making payment on
the individual’s own behalf (or on behalf of
a 
relative 
or 
other 
individual) 
for
deductibles, coinsurance, or services not
covered under a health benefit plan; and
(iv) such other plans as the Secretary
may determine, because of the limitation of
benefits to a single type or kind of health
care, such as dental services, or other rea-
sons should not be subject to the require-
ments of this section.
(C) PLANS
INCLUDED.—Such term in-
cludes—
(i) worker’s compensation or similar
insurance, and