125 
SEC. 133. PROHIBITION AGAINST IMPROPER INCENTIVE 
ARRANGEMENTS. 
(a) IN GENERAL.—A group health plan and a health 
insurance issuer offering health insurance coverage may 
not operate any physician incentive plan (as defined in 
subparagraph (B) of section 1852(j)(4) of the Social Secu-
rity Act) unless the requirements described in clauses (i), 
(ii)(I), and (iii) of subparagraph (A) of such section are 
met with respect to such a plan. 
(b) APPLICATION.—For purposes of carrying out 
paragraph (1), any reference in section 1852(j)(4) of the 
Social Security Act to the Secretary, a MedicareAdvantage 
organization, or an individual enrolled with the organiza-
tion shall be treated as a reference to the applicable au-
thority, a group health plan or health insurance issuer, 
respectively, and a participant, beneficiary, or enrollee 
with the plan or organization, respectively. 
(c) CONSTRUCTION.—Nothing in this section shall be 
construed as prohibiting all capitation and similar ar-
rangements or all provider discount arrangements. 
SEC. 134. PAYMENT OF CLAIMS. 
A group health plan, and a health insurance issuer 
offering health insurance coverage, shall provide for 
prompt payment of claims submitted for health care serv-
ices or supplies furnished to a participant, beneficiary, or 
enrollee with respect to benefits covered by the plan or
126 
issuer, in a manner that is no less protective than the pro-
visions of section 1842(c)(2) of the Social Security Act 
(42 U.S.C. 1395u(c)(2)). 
SEC. 135. PROTECTION FOR PATIENT ADVOCACY. 
(a) PROTECTION FOR USE OF UTILIZATION REVIEW 
AND GRIEVANCE PROCESS.—A group health plan, and a 
health insurance issuer with respect to the provision of 
health insurance coverage, may not retaliate against a par-
ticipant, beneficiary, enrollee, or health care provider 
based on the participant’s, beneficiary’s, enrollee’s or pro-
vider’s use of, or participation in, a utilization review proc-
ess or a grievance process of the plan or issuer (including 
an internal or external review or appeal process) under 
this title. 
(b) PROTECTION
FOR
QUALITY
ADVOCACY
BY 
HEALTH CARE PROFESSIONALS.— 
(1) IN GENERAL.—A group health plan and a 
health insurance issuer may not retaliate or dis-
criminate against a protected health care profes-
sional because the professional in good faith— 
(A) discloses information relating to the 
care, services, or conditions affecting one or 
more participants, beneficiaries, or enrollees of 
the plan or issuer to an appropriate public reg-
ulatory agency, an appropriate private accredi-
127 
tation body, or appropriate management per-
sonnel of the plan or issuer; or 
(B) initiates, cooperates, or otherwise par-
ticipates in an investigation or proceeding by 
such an agency with respect to such care, serv-
ices, or conditions. 
If an institutional health care provider is a partici-
pating provider with such a plan or issuer or other-
wise receives payments for benefits provided by such 
a plan or issuer, the provisions of the previous sen-
tence shall apply to the provider in relation to care, 
services, or conditions affecting one or more patients 
within an institutional health care provider in the 
same manner as they apply to the plan or issuer in 
relation to care, services, or conditions provided to 
one or more participants, beneficiaries, or enrollees; 
and for purposes of applying this sentence, any ref-
erence to a plan or issuer is deemed a reference to 
the institutional health care provider. 
(2) GOOD
FAITH
ACTION.—For purposes of 
paragraph (1), a protected health care professional 
is considered to be acting in good faith with respect 
to disclosure of information or participation if, with 
respect to the information disclosed as part of the 
action—