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 group 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 
issuer, in a manner consistent with the provisions of sec-
tions 1816(c)(2) and 1842(c)(2) of the Social Security Act 
(42 U.S.C. 1395h(c)(2) and 42 U.S.C. 1395u(c)(2)), ex-
cept that for purposes of this section, subparagraph (C) 
of section 1816(c)(2) of the Social Security Act shall be 
treated as applying to claims received from a participant, 
beneficiary, or enrollee as well as claims referred to in 
such subparagraph. 
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 
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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 or 
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-
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 
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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— 
(A) the disclosure is made on the basis of 
personal knowledge and is consistent with that 
degree of learning and skill ordinarily possessed 
by health care professionals with the same li-
censure or certification and the same experi-
ence; 
(B) the professional reasonably believes the 
information to be true; 
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(C) the information evidences either a vio-
lation of a law, rule, or regulation, of an appli-
cable accreditation standard, or of a generally 
recognized professional or clinical standard or 
that a patient is in imminent hazard of loss of 
life or serious injury; and 
(D) subject to subparagraphs (B) and (C) 
of paragraph (3), the professional has followed 
reasonable internal procedures of the plan, 
issuer, or institutional health care provider es-
tablished for the purpose of addressing quality 
concerns before making the disclosure. 
(3) EXCEPTION AND SPECIAL RULE.— 
(A) GENERAL EXCEPTION.—Paragraph (1) 
does not protect disclosures that would violate 
Federal or State law or diminish or impair the 
rights of any person to the continued protection 
of confidentiality of communications provided 
by such law. 
(B) NOTICE OF INTERNAL PROCEDURES.— 
Subparagraph (D) of paragraph (2) shall not 
apply unless the internal procedures involved 
are reasonably expected to be known to the 
health care professional involved. For purposes 
of this subparagraph, a health care professional 
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is reasonably expected to know of internal pro-
cedures if those procedures have been made 
available to the professional through distribu-
tion or posting. 
(C) INTERNAL PROCEDURE EXCEPTION.— 
Subparagraph (D) of paragraph (2) also shall 
not apply if— 
(i) the disclosure relates to an immi-
nent hazard of loss of life or serious injury 
to a patient; 
(ii) the disclosure is made to an ap-
propriate private accreditation body pursu-
ant to disclosure procedures established by 
the body; or 
(iii) the disclosure is in response to an 
inquiry made in an investigation or pro-
ceeding of an appropriate public regulatory 
agency and the information disclosed is 
limited to the scope of the investigation or 
proceeding. 
(4) ADDITIONAL
CONSIDERATIONS.—It shall 
not be a violation of paragraph (1) to take an ad-
verse action against a protected health care profes-
sional if the plan, issuer, or provider taking the ad-
verse action involved demonstrates that it would 
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have taken the same adverse action even in the ab-
sence of the activities protected under such para-
graph. 
(5) NOTICE.—A group health plan, health in-
surance issuer, and institutional health care provider 
shall post a notice, to be provided or approved by 
the Secretary of Labor, setting forth excerpts from, 
or summaries of, the pertinent provisions of this 
subsection and information pertaining to enforce-
ment of such provisions. 
(6) CONSTRUCTIONS.— 
(A) DETERMINATIONS
OF
COVERAGE.— 
Nothing in this subsection shall be construed to 
prohibit a plan or issuer from making a deter-
mination not to pay for a particular medical 
treatment or service or the services of a type of 
health care professional. 
(B) ENFORCEMENT OF PEER REVIEW PRO-
TOCOLS AND INTERNAL PROCEDURES.—Noth-
ing in this subsection shall be construed to pro-
hibit a plan, issuer, or provider from estab-
lishing and enforcing reasonable peer review or 
utilization review protocols or determining 
whether a protected health care professional has 
complied with those protocols or from estab-
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lishing and enforcing internal procedures for 
the purpose of addressing quality concerns. 
(C) RELATION TO OTHER RIGHTS.—Noth-
ing in this subsection shall be construed to 
abridge rights of participants, beneficiaries, en-
rollees, and protected health care professionals 
under other applicable Federal or State laws. 
(7) PROTECTED HEALTH CARE PROFESSIONAL 
DEFINED.—For purposes of this subsection, the 
term ‘‘protected health care professional’’ means an 
individual who is a licensed or certified health care 
professional and who— 
(A) with respect to a group health plan or 
health insurance issuer, is an employee of the 
plan or issuer or has a contract with the plan 
or issuer for provision of services for which ben-
efits are available under the plan or issuer; or 
(B) with respect to an institutional health 
care provider, is an employee of the provider or 
has a contract or other arrangement with the 
provider respecting the provision of health care 
services. 
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Subtitle E—Definitions 
SEC. 151. DEFINITIONS. 
(a) INCORPORATION OF GENERAL DEFINITIONS.— 
Except as otherwise provided, the provisions of section 
2791 of the Public Health Service Act shall apply for pur-
poses of this title in the same manner as they apply for 
purposes of title XXVII of such Act. 
(b) SECRETARY.—Except as otherwise provided, the 
term ‘‘Secretary’’ means the Secretary of Health and 
Human Services, in consultation with the Secretary of 
Labor and the term ‘‘appropriate Secretary’’ means the 
Secretary of Health and Human Services in relation to 
carrying out this title under sections 2706 and 2751 of 
the Public Health Service Act and the Secretary of Labor 
in relation to carrying out this title under section 713 of 
the Employee Retirement Income Security Act of 1974. 
(c) ADDITIONAL DEFINITIONS.—For purposes of this 
title: 
(1) ACTIVELY PRACTICING.—The term ‘‘actively 
practicing’’ means, with respect to a physician or 
other health care professional, such a physician or 
professional who provides professional services to in-
dividual patients on average at least two full days 
per week. 
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(2) APPLICABLE AUTHORITY.—The term ‘‘ap-
plicable authority’’ means— 
(A) in the case of a group health plan, the 
Secretary of Health and Human Services and 
the Secretary of Labor; and 
(B) in the case of a health insurance issuer 
with respect to a specific provision of this title, 
the applicable State authority (as defined in 
section 2791(d) of the Public Health Service 
Act), or the Secretary of Health and Human 
Services, if such Secretary is enforcing such 
provision 
under 
section 
2722(a)(2) 
or 
2761(a)(2) of the Public Health Service Act. 
(3) CLINICAL PEER.—The term ‘‘clinical peer’’ 
means, with respect to a review or appeal, an ac-
tively practicing physician (allopathic or osteopathic) 
or other actively practicing health care professional 
who holds a nonrestricted license, and who is appro-
priately credentialed in the same or similar specialty 
or subspecialty (as appropriate) as typically handles 
the medical condition, procedure, or treatment under 
review or appeal and includes a pediatric specialist 
where appropriate; except that only a physician 
(allopathic or osteopathic) may be a clinical peer 
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with respect to the review or appeal of treatment 
recommended or rendered by a physician. 
(4) ENROLLEE.—The term ‘‘enrollee’’ means, 
with respect to health insurance coverage offered by 
a health insurance issuer, an individual enrolled with 
the issuer to receive such coverage. 
(5) GROUP HEALTH PLAN.—The term ‘‘group 
health plan’’ has the meaning given such term in 
section 733(a) of the Employee Retirement Income 
Security Act of 1974 and in section 2791(a)(1) of 
the Public Health Service Act. 
(6) HEALTH CARE PROFESSIONAL.—The term 
‘‘health care professional’’ means an individual who 
is licensed, accredited, or certified under State law 
to provide specified health care services and who is 
operating within the scope of such licensure, accredi-
tation, or certification. 
(7) HEALTH
CARE
PROVIDER.—The term 
‘‘health care provider’’ includes a physician or other 
health care professional, as well as an institutional 
or other facility or agency that provides health care 
services and that is licensed, accredited, or certified 
to provide health care items and services under ap-
plicable State law. 
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(8) NETWORK.—The term ‘‘network’’ means, 
with respect to a group health plan or health insur-
ance issuer offering health insurance coverage, the 
participating health care professionals and providers 
through whom the plan or issuer provides health 
care items and services to participants, beneficiaries, 
or enrollees. 
(9) 
NONPARTICIPATING.—The 
term 
‘‘non-
participating’’ means, with respect to a health care 
provider that provides health care items and services 
to a participant, beneficiary, or enrollee under group 
health plan or health insurance coverage, a health 
care provider that is not a participating health care 
provider with respect to such items and services. 
(10) 
PARTICIPATING.—The 
term 
‘‘partici-
pating’’ means, with respect to a health care pro-
vider that provides health care items and services to 
a participant, beneficiary, or enrollee under group 
health plan or health insurance coverage offered by 
a health insurance issuer, a health care provider that 
furnishes such items and services under a contract 
or other arrangement with the plan or issuer. 
(11) PRIOR AUTHORIZATION.—The term ‘‘prior 
authorization’’ means the process of obtaining prior 
approval from a health insurance issuer or group 
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health plan for the provision or coverage of medical 
services. 
SEC. 152. PREEMPTION; STATE FLEXIBILITY; CONSTRUC-
TION. 
(a) CONTINUED APPLICABILITY
OF STATE LAW 
WITH RESPECT TO HEALTH INSURANCE ISSUERS.— 
(1) IN GENERAL.—Subject to paragraph (2), 
this title shall not be construed to supersede any 
provision of State law which establishes, implements, 
or continues in effect any standard or requirement 
solely relating to health insurance issuers (in connec-
tion with group health insurance coverage or other-
wise) except to the extent that such standard or re-
quirement prevents the application of a requirement 
of this title. 
(2) CONTINUED
PREEMPTION
WITH
RESPECT 
TO GROUP HEALTH PLANS.—Nothing in this title 
shall be construed to affect or modify the provisions 
of section 514 of the Employee Retirement Income 
Security Act of 1974 with respect to group health 
plans. 
(b) DEFINITIONS.—For purposes of this section: 
(1) STATE
LAW.—The term ‘‘State law’’ in-
cludes all laws, decisions, rules, regulations, or other 
State action having the effect of law, of any State. 
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