ceives a denial notice under subparagraph
(C), or
‘‘(ii) in the case in which such a re-
consideration or appeal is taken, the re-
fund is made within 15 days after the date
the supplier receives notice of an adverse
determination on reconsideration or ap-
peal.’’.
(b) CONFORMING AMENDMENT.—Section 1834(h)(3)
(42 U.S.C. 1395m(h)(3)) of such Act is amended by strik-
ing ‘‘Paragraph (12)’’ and inserting ‘‘Paragraphs (12)
and (17)’’.
(c) EFFECTIVE DATE.—The amendments made by
subsections (a) and (b) shall apply to items furnished after
the expiration of the 60-day period that begins on the date
of the enactment of this Act.
SEC. 208. INTERMEDIATE SANCTIONS FOR MEDICARE
HEALTH MAINTENANCE ORGANIZATIONS.
(a) APPLICATION OF INTERMEDIATE SANCTIONS FOR
ANY PROGRAM VIOLATIONS.—
(1) IN
GENERAL.—Section 1876(i)(1) of the
Social Security Act (42 U.S.C. 1395mm(i)(1)) is
amended by striking ‘‘the Secretary may terminate’’
and all that follows and inserting the following: ‘‘in
accordance with procedures established under para-
graph (9), the Secretary may at any time terminate
any such contract or may impose the intermediate
sanctions described in paragraph (6)(B) or (6)(C)
(whichever is applicable) on the eligible organization
if the Secretary determines that the organization—
‘‘(A) has failed substantially to carry out the
contract;
‘‘(B) is carrying out the contract in a manner
inconsistent with the efficient and effective adminis-
tration of this section;
‘‘(C) is operating in a manner that is not in the
best interests of the individuals covered under the
contract; or
‘‘(D) no longer substantially meets the applica-
ble conditions of subsections (b), (c), (e), and (f).’’.
(2) OTHER
INTERMEDIATE
SANCTIONS
FOR
MISCELLANEOUS
PROGRAM
VIOLATIONS.—Section
1876(i)(6) of such Act (42 U.S.C. 1395mm(i)(6)) is
amended by adding at the end the following new
subparagraph:
‘‘(C) In the case of an eligible organization for which
the Secretary makes a determination under paragraph (1)
the basis of which is not described in subparagraph (A),
the Secretary may apply the following intermediate sanc-
tions:
‘‘(i) civil money penalties of not more than
$25,000 for each determination under paragraph (1)
if the deficiency that is the basis of the determina-
tion has directly adversely affected (or has the sub-
stantial likelihood of adversely affecting) an individ-
ual covered under the organization’s contract;
‘‘(ii) civil money penalties of not more than
$10,000 for each week beginning after the initiation
of procedures by the Secretary under paragraph (9)
during which the deficiency that is the basis of a de-
termination under paragraph (1) exists; and
‘‘(iii) suspension of enrollment of individuals
under this section after the date the Secretary noti-
fies the organization of a determination under para-
graph (1) and until the Secretary is satisfied that
the deficiency that is the basis for the determination
has been corrected and is not likely to recur.’’.
(3) PROCEDURES FOR IMPOSING SANCTIONS.—
Section 1876(i) of such Act (42 U.S.C. 1395mm(i))
is amended by adding at the end the following new
paragraph:
‘‘(9) The Secretary may terminate a contract with an
eligible organization under this section or may impose the
intermediate sanctions described in paragraph (6) on the
organization in accordance with formal investigation and
compliance procedures established by the Secretary under
which—
‘‘(A) the Secretary provides the organization
with the opportunity to develop and implement a
corrective action plan to correct the deficiencies that
were the basis of the Secretary’s determination
under paragraph (1);
‘‘(B) the Secretary shall impose more severe
sanctions on organizations that have a history of de-
ficiencies or that have not taken steps to correct de-
ficiencies the Secretary has brought to their atten-
tion;
‘‘(C) there are no unreasonable or unnecessary
delays between the finding of a deficiency and the
imposition of sanctions; and
‘‘(D) the Secretary provides the organization
with reasonable notice and opportunity for hearing
(including the right to appeal an initial decision) be-
fore imposing any sanction or terminating the con-
tract.’’.
(4) CONFORMING AMENDMENTS.—(A) Section
1876(i)(6)(B) 
of 
such 
Act 
(42 
U.S.C.
1395mm(i)(6)(B)) is amended by striking the sec-
ond sentence.
(B) Section 1876(i)(6) of such Act (42 U.S.C.
1395mm(i)(6)) is further amended by adding at the
end the following new subparagraph:
‘‘(D) The provisions of section 1128A (other than
subsections (a) and (b)) shall apply to a civil money pen-
alty under subparagraph (A) or (B) in the same manner
as they apply to a civil money penalty or proceeding under
section 1128A(a).’’.
(b) AGREEMENTS WITH PEER REVIEW ORGANIZA-
TIONS.—
(1) REQUIREMENT
FOR
WRITTEN
AGREE-
MENT.—Section 1876(i)(7)(A) of the Social Security
Act (42 U.S.C. 1395mm(i)(7)(A)) is amended by
striking ‘‘an agreement’’ and inserting ‘‘a written
agreement’’.
(2) DEVELOPMENT OF MODEL AGREEMENT.—
Not later than July 1, 1994, the Secretary of Health
and Human Services shall develop a model of the
agreement that an eligible organization with a risk-
sharing contract under section 1876 of the Social
Security Act must enter into with an entity provid-
ing peer review services with respect to services pro-
vided 
by 
the 
organization 
under 
section
1876(i)(7)(A) of such Act.
(3) REPORT BY GAO.—
(A) STUDY.—The Comptroller General
shall conduct a study of the costs incurred by
eligible organizations with risk-sharing con-
tracts under section 1876(b) of such Act of
complying with the requirement of entering into
a written agreement with an entity providing
peer review services with respect to services pro-
vided by the organization, together with an
analysis of how information generated by such
entities is used by the Secretary of Health and
Human Services to assess the quality of
services provided by such eligible organizations.
(B) REPORT
TO
CONGRESS.—Not later
than July 1, 1996, the Comptroller General
shall submit a report to the Committee on
Ways and Means and the Committee on Energy
and Commerce of the House of Representatives
and the Committee on Finance of the Senate on
the study conducted under subparagraph (A).
(c) EFFECTIVE DATE.—The amendments made by
this section shall apply with respect to contract years be-
ginning on or after January 1, 1995.
SEC. 209. EFFECTIVE DATE.
Except as otherwise provided in section 207(c), the
amendments made by this title shall take effect January
1, 1995.
TITLE 
III—ADMINISTRATIVE
AND MISCELLANEOUS PROVI-
SIONS
SEC. 301. REQUIREMENTS FOR UNIFORM CLAIMS AND
ELECTRONIC CLAIMS DATA SET.
(a) REQUIREMENTS.—
(1) SUBMISSION OF CLAIMS.—Each health serv-
ice provider that furnishes services in the United
States for which payment may be made under a
health benefit plan shall submit any claim for pay-
ment for such services only in a form and manner
consistent with standards established under sub-
section (c).
(2) ACCEPTANCE OF CLAIMS.—A health benefit
plan may not reject a claim for payment under the
plan on the basis of the form or manner in which
the claim is submitted if the claim is submitted in
accordance with the standards established under
subsection (c).
(3) EFFECTIVE
DATE.—This subsection shall
apply to claims for services furnished on or after the