II 
117TH CONGRESS 
2D SESSION 
H. R. 3173 
IN THE SENATE OF THE UNITED STATES 
SEPTEMBER 15, 2022 
Received 
AN ACT 
To amend title XVIII of the Social Security Act to establish 
requirements with respect to the use of prior authoriza-
tion under Medicare Advantage plans, and for other pur-
poses. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
VerDate Sep 11 2014 
02:04 Jan 04, 2023
Jkt 039200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6201
E:\BILLS\H3173.RDS
H3173
kjohnson on DSK79L0C42PROD with BILLS
HR 3173 RDS
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Improving Seniors’ 
Timely Access to Care Act of 2022’’. 
SEC. 2. ESTABLISHING REQUIREMENTS WITH RESPECT TO 
THE USE OF PRIOR AUTHORIZATION UNDER 
MEDICARE ADVANTAGE PLANS. 
(a) IN GENERAL.—Section 1852 of the Social Secu-
rity Act (42 U.S.C. 1395w–22) is amended by adding at 
the end the following new subsection: 
‘‘(o) PRIOR AUTHORIZATION REQUIREMENTS.— 
‘‘(1) IN GENERAL.—In the case of a Medicare 
Advantage plan that imposes any prior authorization 
requirement with respect to any applicable item or 
service (as defined in paragraph (5)) during a plan 
year, such plan shall— 
‘‘(A) beginning with the third plan year be-
ginning after the date of the enactment of this 
subsection— 
‘‘(i) establish the electronic prior au-
thorization program described in para-
graph (2); and 
‘‘(ii) meet the enrollee protection 
standards specified pursuant to paragraph 
(4); and 
‘‘(B) beginning with the fourth plan year 
beginning after the date of the enactment of 
VerDate Sep 11 2014 
02:04 Jan 04, 2023
Jkt 039200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6201
E:\BILLS\H3173.RDS
H3173
kjohnson on DSK79L0C42PROD with BILLS
HR 3173 RDS
this subsection, meet the transparency require-
ments specified in paragraph (3). 
‘‘(2) ELECTRONIC PRIOR AUTHORIZATION PRO-
GRAM.— 
‘‘(A) IN GENERAL.—For purposes of para-
graph (1)(A), the electronic prior authorization 
program described in this paragraph is a pro-
gram that provides for the secure electronic 
transmission of— 
‘‘(i) a prior authorization request 
from a provider of services or supplier to 
a Medicare Advantage plan with respect to 
an applicable item or service to be fur-
nished to an individual and a response, in 
accordance with this paragraph, from such 
plan to such provider or supplier; and 
‘‘(ii) any attachment relating to such 
request or response. 
‘‘(B) ELECTRONIC TRANSMISSION.— 
‘‘(i) EXCLUSIONS.—For purposes of 
this paragraph, a facsimile, a proprietary 
payer portal that does not meet standards 
specified by the Secretary, or an electronic 
form shall not be treated as an electronic 
VerDate Sep 11 2014 
02:04 Jan 04, 2023
Jkt 039200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6201
E:\BILLS\H3173.RDS
H3173
kjohnson on DSK79L0C42PROD with BILLS
HR 3173 RDS
transmission described in subparagraph 
(A). 
‘‘(ii) 
STANDARDS.—An 
electronic 
transmission described in subparagraph 
(A) shall comply with— 
‘‘(I) applicable technical stand-
ards adopted by the Secretary pursu-
ant to section 1173; and 
‘‘(II) other requirements to pro-
mote the standardization and stream-
lining of electronic transactions under 
this part specified by the Secretary. 
‘‘(iii) DEADLINE FOR SPECIFICATION 
OF
ADDITIONAL
REQUIREMENTS.—Not 
later than July 1, 2023, the Secretary 
shall finalize requirements described in 
clause (ii)(II). 
‘‘(C) REAL-TIME DECISIONS.— 
‘‘(i) IN GENERAL.—Subject to clause 
(iv), the program described in subpara-
graph (A) shall provide for real-time deci-
sions (as defined by the Secretary in ac-
cordance with clause (v)) by a Medicare 
Advantage plan with respect to prior au-
thorization requests for applicable items 
VerDate Sep 11 2014 
02:04 Jan 04, 2023
Jkt 039200
PO 00000
Frm 00004
Fmt 6652
Sfmt 6201
E:\BILLS\H3173.RDS
H3173
kjohnson on DSK79L0C42PROD with BILLS
HR 3173 RDS
and services identified by the Secretary 
pursuant to clause (ii) if such requests are 
submitted with all medical or other docu-
mentation required by such plan. 
‘‘(ii) IDENTIFICATION OF ITEMS AND 
SERVICES.— 
‘‘(I) IN GENERAL.—For purposes 
of clause (i), the Secretary shall iden-
tify, not later than the date on which 
the initial announcement described in 
section 1853(b)(1)(B)(i) for the third 
plan year beginning after the date of 
the enactment of this subsection is re-
quired to be announced, applicable 
items and services for which prior au-
thorization requests are routinely ap-
proved. 
‘‘(II) UPDATES.—The Secretary 
shall consider updating the applicable 
items and services identified under 
subclause (I) based on the information 
described in paragraph (3)(A)(i) (if 
available and determined practicable 
to utilize by the Secretary) and any 
other information determined appro-
VerDate Sep 11 2014 
02:04 Jan 04, 2023
Jkt 039200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H3173.RDS
H3173
kjohnson on DSK79L0C42PROD with BILLS
HR 3173 RDS
priate by the Secretary not less fre-
quently than biennially. The Secretary 
shall announce any such update that 
is to apply with respect to a plan year 
not later than the date on which the 
initial announcement described in sec-
tion 1853(b)(1)(B)(i) for such plan 
year is required to be announced. 
‘‘(iii) REQUEST FOR INFORMATION.— 
The Secretary shall issue a request for in-
formation for purposes of initially identi-
fying applicable items and services under 
clause (ii)(I). 
‘‘(iv) EXCEPTION FOR EXTENUATING 
CIRCUMSTANCES.—In the case of a prior 
authorization request submitted to a Medi-
care Advantage plan for an individual en-
rolled in such plan during a plan year with 
respect to an item or service identified by 
the Secretary pursuant to clause (ii) for 
such plan year, such plan may, in lieu of 
providing a real-time decision with respect 
to such request in accordance with clause 
(i), delay such decision under extenuating 
circumstances (as specified by the Sec-
VerDate Sep 11 2014 
02:04 Jan 04, 2023
Jkt 039200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H3173.RDS
H3173
kjohnson on DSK79L0C42PROD with BILLS
HR 3173 RDS
retary), provided that such decision is pro-
vided no later than 72 hours after receipt 
of such request (or, in the case that the 
provider of services or supplier submitting 
such request has indicated that such delay 
may seriously jeopardize such individual’s 
life, health, or ability to regain maximum 
function, no later than 24 hours after re-
ceipt of such request). 
‘‘(v) DEFINITION OF REAL-TIME DECI-
SION.—In establishing the definition of a 
real-time decision for purposes of clause 
(i), the Secretary shall take into account 
current 
medical 
practice, 
technology, 
health care industry standards, and other 
relevant information relating to how quick-
ly a Medicare Advantage plan may provide 
responses with respect to prior authoriza-
tion requests. 
‘‘(vi) IMPLEMENTATION.—The Sec-
retary shall use notice and comment rule-
making for each of the following: 
‘‘(I) Establishing the definition 
of a ‘real-time decision’ for purposes 
of clause (i). 
VerDate Sep 11 2014 
02:04 Jan 04, 2023
Jkt 039200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\H3173.RDS
H3173
kjohnson on DSK79L0C42PROD with BILLS
HR 3173 RDS
‘‘(II) Updating such definition. 
‘‘(III) Initially identifying appli-
cable items or services pursuant to 
clause (ii)(I). 
‘‘(IV) Updating applicable items 
and services so identified as described 
in clause (ii)(II). 
‘‘(3) TRANSPARENCY REQUIREMENTS.— 
‘‘(A) IN GENERAL.—For purposes of para-
graph (1)(B), the transparency requirements 
specified in this paragraph are, with respect to 
a Medicare Advantage plan, the following: 
‘‘(i) The plan, annually and in a man-
ner specified by the Secretary, shall submit 
to the Secretary the following information: 
‘‘(I) A list of all applicable items 
and services that were subject to a 
prior authorization requirement under 
the plan during the previous plan 
year. 
‘‘(II) The percentage and number 
of specified requests (as defined in 
subparagraph (F)) approved during 
the previous plan year by the plan in 
an initial determination and the per-
VerDate Sep 11 2014 
02:04 Jan 04, 2023
Jkt 039200
PO 00000
Frm 00008
Fmt 6652
Sfmt 6201
E:\BILLS\H3173.RDS
H3173
kjohnson on DSK79L0C42PROD with BILLS
HR 3173 RDS
centage and number of specified re-
quests denied during such plan year 
by such plan in an initial determina-
tion (both in the aggregate and cat-
egorized by each item and service). 
‘‘(III) The percentage and num-
ber of specified requests submitted 
during the previous plan year that 
were made with respect to an item or 
service identified by the Secretary 
pursuant to paragraph (2)(C)(ii) for 
such plan year, and the percentage 
and number of such requests that 
were subject to an exception under 
paragraph (2)(C)(iv) (categorized by 
each item and service). 
‘‘(IV) The percentage and num-
ber of specified requests submitted 
during the previous plan year that 
were made with respect to an item or 
service identified by the Secretary 
pursuant to paragraph (2)(C)(ii) for 
such plan year that were approved 
(categorized by each item and serv-
ice). 
VerDate Sep 11 2014 
02:04 Jan 04, 2023
Jkt 039200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H3173.RDS
H3173
kjohnson on DSK79L0C42PROD with BILLS
HR 3173 RDS
‘‘(V) The percentage and number 
of specified requests that were denied 
during the previous plan year by the 
plan in an initial determination and 
that were subsequently appealed. 
‘‘(VI) The number of appeals of 
specified requests resolved during the 
preceding plan year, and the percent-
age and number of such resolved ap-
peals that resulted in approval of the 
furnishing of the item or service that 
was the subject of such request, cat-
egorized by each applicable item and 
service and categorized by each level 
of appeal (including judicial review). 
‘‘(VII) The percentage and num-
ber of specified requests that were de-
nied, and the percentage and number 
of specified requests that were ap-
proved, by the plan during the pre-
vious plan year through the utilization 
of decision support technology, artifi-
cial intelligence technology, machine- 
learning technology, clinical decision- 
VerDate Sep 11 2014 
02:04 Jan 04, 2023
Jkt 039200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\H3173.RDS
H3173
kjohnson on DSK79L0C42PROD with BILLS
HR 3173 RDS
making technology, or any other tech-
nology specified by the Secretary. 
‘‘(VIII) The average and the me-
dian amount of time (in hours) that 
elapsed during the previous plan year 
between the submission of a specified 
request to the plan and a determina-
tion by the plan with respect to such 
request for each such item and serv-
ice, excluding any such requests that 
were not submitted with the medical 
or other documentation required to be 
submitted by the plan. 
‘‘(IX) The percentage and num-
ber of specified requests that were ex-
cluded from the calculation described 
in subclause (VIII) based on the 
plan’s determination that such re-
quests were not submitted with the 
medical or other documentation re-
quired to be submitted by the plan. 
‘‘(X) Information on each occur-
rence during the previous plan year in 
which, during a surgical or medical 
procedure involving the furnishing of 
VerDate Sep 11 2014 
02:04 Jan 04, 2023
Jkt 039200
PO 00000
Frm 00011
Fmt 6652
Sfmt 6201
E:\BILLS\H3173.RDS
H3173
kjohnson on DSK79L0C42PROD with BILLS
HR 3173 RDS
an applicable item or service with re-
spect to which such plan had ap-
proved a prior authorization request, 
the provider of services or supplier 
furnishing such item or service deter-
mined that a different or additional 
item or service was medically nec-
essary, including a specification of 
whether such plan subsequently ap-
proved the furnishing of such dif-
ferent or additional item or service. 
‘‘(XI) A disclosure and descrip-
tion of any technology described in 
subclause (VII) that the plan utilized 
during the previous plan year in mak-
ing determinations with respect to 
specified requests. 
‘‘(XII) The number of grievances 
(as described in subsection (f)) re-
ceived by such plan during the pre-
vious plan year that were related to a 
prior authorization requirement. 
‘‘(XIII) Such other information 
as the Secretary determines appro-
priate. 
VerDate Sep 11 2014 
02:04 Jan 04, 2023
Jkt 039200
PO 00000
Frm 00012
Fmt 6652
Sfmt 6201
E:\BILLS\H3173.RDS
H3173
kjohnson on DSK79L0C42PROD with BILLS
HR 3173 RDS
‘‘(ii) The plan shall provide— 
‘‘(I) to each provider or supplier 
who seeks to enter into a contract 
with such plan to furnish applicable 
items and services under such plan, 
the list described in clause (i)(I) and 
any policies or procedures used by the 
plan for making determinations with 
respect to prior authorization re-
quests; 
‘‘(II) to each such provider and 
supplier that enters into such a con-
tract, access to the criteria used by 
the plan for making such determina-
tions and an itemization of the med-
ical or other documentation required 
to be submitted by a provider or sup-
plier with respect to such a request; 
and 
‘‘(III) to an enrollee of the plan, 
upon request, access to the criteria 
used by the plan for making deter-
minations with respect to prior au-
thorization requests for an item or 
service. 
VerDate Sep 11 2014 
02:04 Jan 04, 2023
Jkt 039200
PO 00000
Frm 00013
Fmt 6652
Sfmt 6201
E:\BILLS\H3173.RDS
H3173
kjohnson on DSK79L0C42PROD with BILLS