187 
essary to achieve or maintain compliance with 
the applicable conditions and requirements of 
titles XVIII and XIX of the Social Security 
Act. Any amounts so received that are in excess 
of the amount necessary to achieve or maintain 
such conditions and requirements shall, subject 
to consultation with the Indian Tribes being 
served by the Service Unit, be used for reducing 
the health resource deficiencies (as determined 
under section 201(d)) of such Indian Tribes. 
‘‘(2) DIRECT
PAYMENT
OPTION.—Paragraph 
(1) shall not apply to a Tribal Health Program upon 
the election of such Program under subsection (d) to 
receive payments directly. No payment may be made 
out of the special fund described in such paragraph 
with respect to reimbursement made for services 
provided by such Program during the period of such 
election. 
‘‘(d) DIRECT BILLING.— 
‘‘(1) IN GENERAL.—Subject to complying with 
the requirements of paragraph (2), a Tribal Health 
Program may elect to directly bill for, and receive 
payment for, health care items and services provided 
by such Program for which payment is made under 
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title XVIII or XIX of the Social Security Act or 
from any other third party payor. 
‘‘(2) DIRECT REIMBURSEMENT.— 
‘‘(A) USE OF FUNDS.—Each Tribal Health 
Program making the election described in para-
graph (1) with respect to a program under a 
title of the Social Security Act shall be reim-
bursed directly by that program for items and 
services furnished without regard to subsection 
(c)(1), but all amounts so reimbursed shall be 
used by the Tribal Health Program for the pur-
pose of making any improvements in facilities 
of the Tribal Health Program that may be nec-
essary to achieve or maintain compliance with 
the conditions and requirements applicable gen-
erally to such items and services under the pro-
gram under such title and to provide additional 
health care services, improvements in health 
care facilities and Tribal Health Programs, any 
health care related purpose, or otherwise to 
achieve the objectives provided in section 3 of 
this Act. 
‘‘(B) AUDITS.—The amounts paid to a 
Tribal Health Program making the election de-
scribed in paragraph (1) with respect to a pro-
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189 
gram under a title of the Social Security Act 
shall be subject to all auditing requirements ap-
plicable to the program under such title, as well 
as all auditing requirements applicable to pro-
grams administered by an Indian Health Pro-
gram. Nothing in the preceding sentence shall 
be construed as limiting the application of au-
diting requirements applicable to amounts paid 
under title XVIII, XIX, or XXI of the Social 
Security Act. 
‘‘(C) IDENTIFICATION OF SOURCE OF PAY-
MENTS.—Any Tribal Health Program that re-
ceives reimbursements or payments under title 
XVIII, XIX, or XXI of the Social Security Act, 
shall provide to the Service a list of each pro-
vider enrollment number (or other identifier) 
under which such Program receives such reim-
bursements or payments. 
‘‘(3) EXAMINATION AND IMPLEMENTATION OF 
CHANGES.— 
‘‘(A) IN GENERAL.—The Secretary, acting 
through the Service and with the assistance of 
the Administrator of the Centers for Medicare 
& Medicaid Services, shall examine on an ongo-
ing basis and implement any administrative 
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190 
changes that may be necessary to facilitate di-
rect billing and reimbursement under the pro-
gram established under this subsection, includ-
ing any agreements with States that may be 
necessary to provide for direct billing under a 
program under a title of the Social Security 
Act. 
‘‘(B) COORDINATION OF INFORMATION.— 
The Service shall provide the Administrator of 
the Centers for Medicare & Medicaid Services 
with copies of the lists submitted to the Service 
under paragraph (2)(C), enrollment data re-
garding patients served by the Service (and by 
Tribal Health Programs, to the extent such 
data is available to the Service), and such other 
information as the Administrator may require 
for purposes of administering title XVIII, XIX, 
or XXI of the Social Security Act. 
‘‘(4) WITHDRAWAL FROM PROGRAM.—A Tribal 
Health Program that bills directly under the pro-
gram established under this subsection may with-
draw from participation in the same manner and 
under the same conditions that an Indian Tribe or 
Tribal Organization may retrocede a contracted pro-
gram to the Secretary under the authority of the In-
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