sion requires the evaluation of medical
facts or evidence by a health professional.
If the expert determines that the coverage
decision requires such evaluation, reconsid-
eration of such adverse decision shall pro-
ceed under this paragraph. If the expert
determines that the coverage decision does
not require such evaluation, the adverse
decision shall remain the final decision of
the plan.
‘‘(ii) INDEPENDENT
CONTRACT
EX-
PERTS.—For purposes of this subpara-
graph, the term ‘independent contract ex-
pert’ means a professional—
‘‘(I) who has appropriate creden-
tials and has attained recognized ex-
pertise in the applicable area of con-
tract interpretation;
‘‘(II) who was not involved in the
initial decision or any earlier review
thereof; and
‘‘(III) who is selected in accord-
ance with subparagraph (G)(i) and
meets the requirements of subpara-
graph (G)(ii).
‘‘(D) RECONSIDERATION
OF
INITIAL
RE-
VIEW DECISION.—
‘‘(i) IN GENERAL.—In the case of a
request for review made by a participant or
beneficiary as described in subparagraph
(A), if the requirements of subparagraph
(A)(i) are met or reconsideration proceeds
under this paragraph pursuant to subpara-
graph (C), the terms of the plan shall pro-
vide for a procedure for such reconsider-
ation in accordance with clause (ii).
‘‘(ii) PROCEDURE
FOR
RECONSIDER-
ATION.—The procedure required under
clause (i) shall include the following—
‘‘(I) One or more independent
medical experts will be selected in ac-
cordance with subparagraph (F) to re-
consider any coverage decision de-
scribed in subparagraph (A) to deter-
mine whether such decision was in ac-
cordance with the terms of the plan
and this title.
‘‘(II) The record for review (in-
cluding a specification of the terms of
the plan and other criteria serving as
the basis for the initial review deci-
sion) will be presented to such expert
or experts and maintained in a man-
ner which will ensure confidentiality
of such record.
‘‘(III) Such expert or experts will
reconsider the initial review decision
to determine whether such decision
was in accordance with the terms of
the plan and this title. Such reconsid-
eration shall include the initial deci-
sion of the plan, the medical condition
of the patient, and the recommenda-
tions of the treating physician. The
experts shall take into account in the
course of such reconsideration any
guidelines 
adopted 
by 
the 
plan
through a process involving medical
practitioners and peer-reviewed med-
ical literature identified as such under
criteria established by the Food and
Drug Administration.
‘‘(IV) Such expert or experts will
issue a written decision affirming,
modifying, or reversing the initial re-
view 
decision, 
setting 
forth 
the
grounds for the decision.
‘‘(E) TIME
LIMITS
FOR
RECONSIDER-
ATION.—Any review under this paragraph (in-
cluding any review under subparagraph (C))
shall be completed before the end of the recon-
sideration period (as defined in paragraph
(10)(L)) following the review filing date in con-
nection with such review. The decision under
this paragraph affirming, reversing, or modi-
fying the initial review decision of the plan shall
be the final decision of the plan. Failure to
issue a written decision before the end of the
reconsideration period in any reconsideration
requested under this paragraph shall be treated
as a final decision affirming the initial review
decision of the plan.
‘‘(F) INDEPENDENT MEDICAL EXPERTS.—
‘‘(i) IN
GENERAL.—For purposes of
this paragraph, the term ‘independent
medical expert’ means, in connection with
any coverage decision by a group health
plan, a professional—
‘‘(I) who is a physician or, if ap-
propriate, another medical profes-
sional;
‘‘(II) who has appropriate cre-
dentials and has attained recognized
expertise in the applicable medical
field;
‘‘(III) who was not involved in
the initial decision or any earlier re-
view thereof;
‘‘(IV) who has not history of dis-
ciplinary action or sanctions (includ-
ing, but not limited to, loss of staff
privileges or participation restriction)
taken or pending by any hospital,
health carrier, government, or regu-
latory body; and
‘‘(V) who is selected in accord-
ance with subparagraph (G)(i) and
meets the requirements of subpara-
graph (G)(ii).
‘‘(G) SELECTION OF EXPERTS.—
‘‘(i) IN
GENERAL.—An independent
contract expert or independent medical ex-
pert is selected in accordance with this
clause if—
‘‘(I) the expert is selected by an
intermediary which itself meets the re-
quirements of clause (ii), by means of
a method which ensures that the iden-
tity of the expert is not disclosed to
the plan, any health insurance issuer
offering health insurance coverage to
the aggrieved participant or bene-
ficiary in connection with the plan,
and the aggrieved participant or bene-
ficiary under the plan, and the identi-
ties of the plan, the issuer, and the
aggrieved participant or beneficiary
are not disclosed to the expert; or
‘‘(II) the expert is selected, by an
intermediary or otherwise, in a man-
ner that is, under regulations issued
pursuant to negotiated rulemaking,
sufficient to ensure the expert’s inde-
pendence, including selection by the
plan in cases where it is determined
that a suitable intermediary is not
reasonably available,
and the method of selection is devised to
reasonably ensure that the expert selected
meets the independence requirements of
clause (ii).
‘‘(ii) 
INDEPENDENCE
REQUIRE-
MENTS.—An independent contract expert
or independent medical expert or another
entity described in clause (i) meets the
independence requirements of this clause
if—
‘‘(I) the expert or entity is not
affiliated with any related party;
‘‘(II) any compensation received
by such expert or entity in connection
with the external review is reasonable
and not contingent on any decision
rendered by the expert or entity;
‘‘(III) under the terms of the
plan and any health insurance cov-
erage offered in connection with the
plan, the plan and the issuer (if any)
have no recourse against the expert or
entity in connection with the external
review; and
‘‘(IV) the expert or entity does
not otherwise have a conflict of inter-
est with a related party as determined
under any regulations which the Sec-
retary may prescribe.
‘‘(iii) RELATED
PARTY.—For pur-
poses of clause (i)(I), the term ‘related
party’ means—
‘‘(I) the plan or any health insur-
ance issuer offering health insurance
coverage in connection with the plan
(or any officer, director, or manage-
ment employee of such plan or issuer);
‘‘(II) the physician or other med-
ical care provider that provided the
medical care involved in the coverage
decision;
‘‘(III) the institution at which
the medical care involved in the cov-
erage decision is provided;
‘‘(IV) the manufacturer of any
drug or other item that was included
in the medical care involved in the
coverage decision; or
‘‘(V) any other party determined
under any regulations which the Sec-
retary may prescribe to have a sub-
stantial interest in the coverage deci-
sion.
‘‘(iv) AFFILIATED.—For purposes of
clause (ii)(I), the term ‘affiliated’ means,
in connection with any entity, having a fa-
milial, financial, or professional relation-
ship with, or interest in, such entity.
‘‘(H) MISBEHAVIOR
BY
EXPERTS.—Any
action by the expert or experts in applying for
their selection under this paragraph or in the
course of carrying out their duties under this
paragraph which constitutes—
‘‘(i) fraud or intentional misrepresen-
tation by such expert or experts, or
‘‘(ii) demonstrates failure to adhere to
the standards for selection set forth in sub-
paragraph (G)(ii),
shall be treated as a failure to meet the require-
ments of this paragraph and therefore as a
cause of action which may be brought by a fidu-
ciary under section 502(a)(3).
‘‘(5) PERMITTED ALTERNATIVES TO REQUIRED
INTERNAL REVIEW.—
‘‘(A) IN
GENERAL.—In accordance with
such regulations (if any) as may be prescribed
by the Secretary for purposes of this paragraph,
in the case of any initial coverage decision for
benefits 
under 
paragraph 
(2)(A)(ii) 
or
(2)(B)(ii), a group health plan may provide an
alternative dispute resolution procedure meeting
the requirements of subparagraph (B) for use
in lieu of the procedures set forth under the
preceding provisions of this subsection relating
review of such decision. Such procedure may be
provided in one form for all participants and
beneficiaries or in a different form each group
of similarly situated participants and bene-
ficiaries.
‘‘(B) REQUIREMENTS.—An alternative dis-
pute resolution procedure meets the require-
ments of this subparagraph, in connection with
any initial coverage decision, if—
‘‘(i) such procedure is utilized solely—
‘‘(I) accordance with the applica-
ble terms of a bona fide collective bar-
gaining agreement pursuant to which
the plan (or the applicable portion
thereof governed by the agreement) is
established or maintained, or
‘‘(II) upon election by all parties
to such decision,
‘‘(ii) the procedure incorporates time
limits not exceeding the time limits other-
wise applicable under paragraphs (2)(A)(ii)
and (2)(B)(ii);
‘‘(iii) the procedure incorporates any
otherwise applicable requirement for review
by a physician under paragraph (3), unless
waived by the participant or beneficiary (in
a manner consistent with such regulations
as the Secretary may prescribe to ensure
equitable procedures); and
‘‘(iv) the means of resolution of dis-
pute allow for adequate presentation by
each party of scientific and medical evi-
dence supporting the position of such
party.
‘‘(C) WAIVERS.—In any case in which uti-
lization of the alternative dispute resolution
procedure is voluntarily elected by all parties in
connection with a coverage decision, the plan
may require or allow under such procedure (in
a manner consistent with such regulations as
the Secretary may prescribe to ensure equitable
procedures) any party to waive review of the
coverage decision under paragraph (3), to waive
further review of the coverage decision under
paragraph (4) or section 502, and to elect an
alternative means of external review (other than
review under paragraph (4)).
‘‘(6) PERMITTED ALTERNATIVES TO REQUIRED
EXTERNAL REVIEW.—A group health plan shall not
be treated as failing to meet the requirements of this
subsection in connection with review of coverage de-
cisions under paragraph (4) if the aggrieved partici-
pant or beneficiary elects to utilize a procedure in
connection with such review which is made generally
available under the plan (in a manner consistent
with such regulations as the Secretary may prescribe
to ensure equitable procedures) under which—
‘‘(A) the plan agrees in advance of the rec-
ommendations of the independent medical ex-
pert or experts under paragraph (4)(C)(iii) to
render a final decision in accordance with such
recommendations; and
‘‘(B) the participant or beneficiary waives
in advance any right to review of the final deci-
sion under section 502.
‘‘(7) REVIEW REQUIREMENTS.—In any review
of a decision issued under this subsection—
‘‘(A) the record below shall be maintained
for purposes of review in accordance with
standards which shall be prescribed in regula-
tions of the Secretary designed to facilitate
such review, and
‘‘(B) any decision upon review which modi-
fies or reverses a decision below shall specifi-
cally set forth a determination that the record
upon review is sufficient to rebut a presumption
in favor of the decision below.
‘‘(8) COMPLIANCE
WITH
FIDUCIARY
STAND-
ARDS.—The issuance of a decision under a plan
upon review in good faith compliance with the re-
quirements of this subsection shall not be treated as
a violation of part 4.
‘‘(9) GROUP
HEALTH
PLAN
DEFINED.—For
purposes of this section—
‘‘(A) IN
GENERAL.—The term ‘group
health plan’ shall have the meaning provided in
section 733(a).
‘‘(B) TREATMENT
OF
PARTNERSHIPS.—
The provisions of paragraphs (1), (2), and (3)
of section 732(d) shall apply.
‘‘(10) OTHER DEFINITIONS.—For purposes of
this subsection—
‘‘(A) 
REQUEST
FOR
BENEFIT
PAY-
MENTS.—The term ‘request for benefit pay-
ments’ means a request, for payment of benefits
by a group health plan for medical care, which
is made by, or (if expressly authorized) on be-
half of, a participant or beneficiary after such
medical care has been provided.
‘‘(B) REQUIRED DETERMINATION OF MED-
ICAL
NECESSITY.—The term ‘required deter-
mination of medical necessity’ means a deter-
mination required under a group health plan
solely that proposed medical care meets, under
the facts and circumstances at the time of the
determination, the plan’s requirements for med-
ical appropriateness or necessity (which may be
subject to exceptions under the plan for fraud
or misrepresentation), irrespective of whether
the proposed medical care otherwise meets
other terms and conditions of coverage, but
only if such determination does not constitute
an advance determination of coverage (as de-
fined in subparagraph (C)).
‘‘(C) ADVANCE DETERMINATION OF COV-
ERAGE.—The term ‘advance determination of
coverage’ means a determination under a group
health plan that proposed medical care meets,
under the facts and circumstances at the time
of the determination, the plan’s terms and con-
ditions of coverage (which may be subject to ex-
ceptions under the plan for fraud or misrepre-
sentation).
‘‘(D) REQUEST FOR ADVANCE DETERMINA-
TION OF COVERAGE.—The term ‘request for ad-
vance determination of coverage’ means a re-
quest for an advance determination of coverage
of medical care which is made by, or (if ex-
pressly authorized) on behalf of, a participant
or beneficiary before such medical care is pro-
vided.
‘‘(E) REQUEST FOR EXPEDITED ADVANCE
DETERMINATION OF COVERAGE.—The term ‘re-
quest for expedited advance determination of
coverage’ means a request for advance deter-
mination of coverage, in any case in which the
proposed medical care constitutes accelerated
need medical care.
‘‘(F) REQUEST
FOR
REQUIRED
DETER-
MINATION OF MEDICAL NECESSITY.—The term
‘request for required determination of medical
necessity’ means a request for a required deter-
mination of medical necessity for medical care
which is made by or on behalf of a participant
or beneficiary before the medical care is pro-
vided.
‘‘(G) REQUEST FOR EXPEDITED REQUIRED
DETERMINATION
OF
MEDICAL
NECESSITY.—
The term ‘request for expedited required deter-
mination of medical necessity’ means a request
for required determination of medical necessity
in any case in which the proposed medical care
constitutes accelerated need medical care.
‘‘(H) 
ACCELERATED
NEED
MEDICAL
CARE.—The term ‘accelerated need medical
care’ means medical care in any case in which
an appropriate physician has certified in writing
(or as otherwise provided in regulations of the
Secretary) that the participant or beneficiary is
stabilized and—
‘‘(i) that failure to immediately pro-
vide the care to the participant or bene-
ficiary could reasonably be expected to re-
sult in—
‘‘(I) placing the health of such
participant or beneficiary (or, with re-
spect to such a participant or bene-
ficiary who is a pregnant woman, the
health of the woman or her unborn
child) in serious jeopardy;
‘‘(II) serious impairment to bod-
ily functions; or
‘‘(III) serious dysfunction of any
bodily organ or part; or
‘‘(ii) that immediate provision of the
care is necessary because the participant
or beneficiary has made or is at serious
risk of making an attempt to harm himself
or herself or another individual.
‘‘(I) INITIAL DECISION PERIOD.—The term
‘initial decision period’ means a period of 30
days, or such longer period as may be pre-
scribed in regulations of the Secretary.
‘‘(J) INTERNAL
REVIEW
PERIOD.—The
term ‘internal review period’ means a period of
30 days, or such longer period as may be pre-
scribed in regulations of the Secretary.
‘‘(K) ACCELERATED NEED DECISION PE-
RIOD.—The term ‘accelerated need decision pe-
riod’ means a period of 5 days, or such longer
period as may be prescribed in regulations of
the Secretary.
‘‘(L) 
RECONSIDERATION
PERIOD.—The
term ‘reconsideration period’ means a period of
25 days, or such longer period as may be pre-
scribed in regulations of the Secretary, except
that—
‘‘(i) in the case of a decision involving
urgent medical care, such term means the
urgent decision period; and
‘‘(ii) in the case of a decision involving
accelerated need medical care, such term
means the accelerated need decision period.
‘‘(M) FILING
COMPLETION
DATE.—The
term ‘filing completion date’ means, in connec-
tion with a group health plan, the date as of
which the plan is in receipt of all information
reasonably required (in writing or in such other
reasonable form as may be specified by the
plan) to make an initial coverage decision.
‘‘(N) REVIEW
FILING
DATE.—The term
‘review filing date’ means, in connection with a
group health plan, the date as of which the ap-
propriate named fiduciary (or the independent
medical expert or experts in the case of a review
under paragraph (4)) is in receipt of all infor-
mation reasonably required (in writing or in
such other reasonable form as may be specified
by the plan) to make a decision to affirm, mod-
ify, or reverse a coverage decision.
‘‘(O) MEDICAL CARE.—The term ‘medical
care’ has the meaning provided such term by
section 733(a)(2).
‘‘(P) HEALTH
INSURANCE
COVERAGE.—
The term ‘health insurance coverage’ has the
meaning 
provided 
such 
term 
by 
section
733(b)(1).
‘‘(Q) HEALTH
INSURANCE
ISSUER.—The
term ‘health insurance issuer’ has the meaning
provided such term by section 733(b)(2).
‘‘(R) WRITTEN OR IN WRITING.—
‘‘(i) IN GENERAL.—A request or deci-
sion shall be deemed to be ‘written’ or ‘in
writing’ if such request or decision is pre-
sented in a generally recognized printable
or electronic format. The Secretary may by
regulation provide for presentation of in-
formation otherwise required to be in writ-
ten form in such other forms as may be
appropriate under the circumstances.
‘‘(ii) MEDICAL APPROPRIATENESS OR
INVESTIGATIONAL
ITEMS
OR
EXPERI-
MENTAL TREATMENT DETERMINATIONS.—
For purposes of this subparagraph, in the
case of a request for advance determina-
tion of coverage, a request for expedited
advance determination of coverage, a re-
quest for required determination of medical
necessity, or a request for expedited re-
quired determination of medical necessity,
if the decision on such request is conveyed
to the provider of medical care or to the
participant or beneficiary by means of tele-
phonic or other electronic communications,
such decision shall be treated as a written
decision.’’.
SEC. 3. CLARIFICATION OF ERISA PREEMPTION RULES.
(a) IN GENERAL.—Section 514 of the Employee Re-
tirement Income Security Act of 1974 (29 U.S.C. 1144)
is amended—
(1) by redesignating subsection (d) as sub-
section (e); and
(2) by inserting after subsection (c) the fol-
lowing new subsection:
‘‘(d) The procedures and remedies required or pro-
vided under sections 502 and 503 in connection with—
‘‘(1) review of claims for benefits under em-
ployee benefit plans and for review of decisions deny-
ing such claims (including review of coverage deci-
sions referred to in section 503(b) and decisions
upon review of such coverage decisions), and
‘‘(2) causes of action brought to recover plan
benefits, to enforce rights under the terms of the
plan or this title, or to clarify rights to future bene-
fits under the terms of the plan or this title,
are the exclusive procedures and remedies with respect to
any such review or cause of action and supersede any pro-
vision of State law providing for any such review or cause
of action.’’.
(b) 
CONFORMING
AMENDMENT.—Section
514(b)(2)(A) of such Act (42 U.S.C. 1144(b)(2)(A)) is
amended by inserting ‘‘or subsection (d)’’ after ‘‘subpara-
graph (B)’’.
SEC. 4. EFFECTIVE DATE.
(a) IN GENERAL.—The amendments made by this
Act shall apply with respect to grievances arising in plan
years beginning on or after January 1 of the second cal-
endar year following 12 months after the date the Sec-
retary of Labor issues all regulations necessary to carry
out amendments made by this Act.
(b) LIMITATION ON ENFORCEMENT ACTIONS.—No
enforcement action shall be taken, pursuant to the amend-
ments made by this Act, against a group health plan or
health insurance issuer with respect to a violation of a re-
quirement imposed by such amendments before the date
of issuance of final regulations issued in connection with
such requirement, if the plan or issuer has sought to com-
ply in good faith with such requirement.
(c) COLLECTIVE BARGAINING AGREEMENTS.—Any
plan amendment made pursuant to a collective bargaining
agreement relating to the plan which amends the plan
solely to conform to any requirement added by this Act
shall not be treated as a termination of such collective bar-
gaining agreement.
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