816
‘‘(2) ELEMENTS OF PROGRAM.—The quality as-
surance program shall—
‘‘(A) stress health outcomes and provide
for the collection, analysis, and reporting of
data (in accordance with a quality measurement
system that the Secretary recognizes) that will
permit measurement of outcomes and other in-
dices of the quality of MedicarePlus plans and
organizations;
‘‘(B) provide for the establishment of writ-
ten protocols for utilization review, based on
current standards of medical practice;
‘‘(C) provide review by physicians and
other health care professionals of the process
followed in the provision of such health care
services;
‘‘(D) monitor and evaluate high volume
and high risk services and the care of acute and
chronic conditions;
‘‘(E) evaluate the continuity and coordina-
tion of care that enrollees receive;
‘‘(F) have mechanisms to detect both un-
derutilization and overutilization of services;
‘‘(G) after identifying areas for improve-
ment, establish or alter practice parameters;
817
‘‘(H) take action to improve quality and
assesses the effectiveness of such action
through systematic followup;
‘‘(I) make available information on quality
and outcomes measures to facilitate beneficiary
comparison and choice of health coverage op-
tions (in such form and on such quality and
outcomes measures as the Secretary determines
to be appropriate);
‘‘(J) be evaluated on an ongoing basis as
to its effectiveness;
‘‘(K) include measures of consumer satis-
faction; and
‘‘(L) provide the Secretary with such ac-
cess to information collected as may be appro-
priate to monitor and ensure the quality of care
provided under this part.
‘‘(3) EXTERNAL REVIEW.—Each MedicarePlus
organization shall, for each MedicarePlus plan it op-
erates, have an agreement with an independent qual-
ity review and improvement organization approved
by the Secretary to perform functions of the type de-
scribed in sections 1154(a)(4)(B) and 1154(a)(14)
with respect to services furnished by MedicarePlus
plans for which payment is made under this title.
818
‘‘(4) TREATMENT
OF
ACCREDITATION.—The
Secretary shall provide that a MedicarePlus organi-
zation is deemed to meet requirements of para-
graphs (1) through (3) of this subsection and sub-
section (h) (relating to confidentiality and accuracy
of enrollee records) if the organization is accredited
(and periodically reaccredited) by a private organiza-
tion under a process that the Secretary has deter-
mined assures that the organization, as a condition
of accreditation, applies and enforces standards with
respect to the requirements involved that are no less
stringent than the standards established under sec-
tion 1856 to carry out the respective requirements.
‘‘(f) COVERAGE DETERMINATIONS.—
‘‘(1) DECISIONS ON NONEMERGENCY CARE.—A
MedicarePlus organization shall make determina-
tions regarding authorization requests for non-
emergency care on a timely basis, depending on the
urgency of the situation.
‘‘(2) RECONSIDERATIONS.—
‘‘(A) IN GENERAL.—Subject to subsection
(g)(4), a reconsideration of a determination of
an organization denying coverage shall be made
within 30 days of the date of receipt of medical
819
information, but not later than 60 days after
the date of the determination.
‘‘(B) PHYSICIAN
DECISION
ON
CERTAIN
RECONSIDERATIONS.—A reconsideration relat-
ing to a determination to deny coverage based
on a lack of medical necessity shall be made
only by a physician other than a physician in-
volved in the initial determination.
‘‘(g) GRIEVANCES AND APPEALS.—
‘‘(1) 
GRIEVANCE
MECHANISM.—Each
MedicarePlus organization must provide meaningful
procedures for hearing and resolving grievances be-
tween the organization (including any entity or indi-
vidual through which the organization provides
health 
care 
services) 
and 
enrollees 
with
MedicarePlus plans of the organization under this
part.
‘‘(2) 
APPEALS.—An 
enrollee 
with 
a
MedicarePlus plan of a MedicarePlus organization
under this part who is dissatisfied by reason of the
enrollee’s failure to receive any health service to
which the enrollee believes the enrollee is entitled
and at no greater charge than the enrollee believes
the enrollee is required to pay is entitled, if the
amount in controversy is $100 or more, to a hearing
820
before the Secretary to the same extent as is pro-
vided in section 205(b), and in any such hearing the
Secretary shall make the organization a party. If the
amount in controversy is $1,000 or more, the indi-
vidual or organization shall, upon notifying the other
party, be entitled to judicial review of the Sec-
retary’s final decision as provided in section 205(g),
and both the individual and the organization shall be
entitled to be parties to that judicial review. In ap-
plying sections 205(b) and 205(g) as provided in
this paragraph, and in applying section 205(l) there-
to, any reference therein to the Commissioner of So-
cial Security or the Social Security Administration
shall be considered a reference to the Secretary or
the Department of Health and Human Services, re-
spectively.
‘‘(3) INDEPENDENT REVIEW OF CERTAIN COV-
ERAGE DENIALS.—The Secretary shall contract with
an independent, outside entity to review and resolve
reconsiderations that affirm denial of coverage.
‘‘(4) EXPEDITED
DETERMINATIONS
AND
RE-
CONSIDERATIONS.—
‘‘(A) RECEIPT OF REQUESTS.—An enrollee
in a MedicarePlus plan may request, either in
writing or orally, an expedited determination or
821
reconsideration by the MedicarePlus organiza-
tion regarding a matter described in paragraph
(2). The organization shall also permit the ac-
ceptance of such requests by physicians.
‘‘(B) ORGANIZATION PROCEDURES.—
‘‘(i) IN GENERAL.—The MedicarePlus
organization shall maintain procedures for
expediting organization determinations and
reconsiderations when, upon request of an
enrollee, the organization determines that
the application of normal time frames for
making a determination (or a reconsider-
ation involving a determination) could seri-
ously jeopardize the life or health of the
enrollee or the enrollee’s ability to regain
maximum function.
‘‘(ii) TIMELY RESPONSE.—In an ur-
gent case described in clause (i), the orga-
nization shall notify the enrollee (and the
physician involved, as appropriate) of the
determination (or determination on the re-
consideration) as expeditiously as the en-
rollee’s health condition requires, but not
later than 72 hours (or 24 hours in the
case of a reconsideration) of the time of re-