111 
mation that the provider was a participating 
provider or facility was a participating facility, 
with respect to the plan for furnishing such 
item or service. 
‘‘(B) A notification was not provided, in 
accordance with subsection (h), to the partici-
pant, beneficiary, or enrollee, and the partici-
pant, beneficiary, or enrollee requested through 
the response protocol of the plan under sub-
section (f)(3) information on whether the pro-
vider was a participating provider or facility 
was a participating facility with respect to the 
plan for furnishing such item or service and 
was informed through such protocol that the 
provider was such a participating provider or 
facility was such a participating facility.’’. 
(b) IRC AMENDMENTS.—Section 9816 of the Inter-
nal Revenue Code of 1986, as added by section 2(b) and 
amended by sections 3(b) and 5(b), is further amended 
by inserting before subsection (k) the following new sub-
sections: 
‘‘(h) ADVANCED EXPLANATION OF BENEFITS.—Be-
ginning on January 1, 2022, each health plan shall, with 
respect to a notification submitted under section 
1150D(b)(2)(A) of the Social Security Act by a health 
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112 
care provider or health care facility, respectively, to the 
health plan for a participant or beneficiary under such 
health plan scheduled to receive an item or service from 
the provider or facility, not later than 1 business day (or, 
in the case such item or service was so scheduled at least 
10 business days before such item or service is to be fur-
nished (or in the case such notification was made pursuant 
to a request by such participant or beneficiary), 3 business 
days) after the date on which the health plan receives such 
notification, provide to the participant or beneficiary 
(through mail or electronic means, as requested by the 
participant or beneficiary) a notification (in clear and 
understable language) including the following: 
‘‘(1) Whether or not the provider or facility is 
a participating provider or a participating facility 
with respect to the health plan with respect to the 
furnishing of such item or service and— 
‘‘(A) in the case the provider or facility is 
a participating provider or facility with respect 
to the health plan with respect to the furnishing 
of such item or service, the contracted rate 
under such plan for such item or service; and 
‘‘(B) in the case the provider or facility is 
a nonparticipating provider or facility with re-
spect to such plan, a description of how such 
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individual may obtain information on providers 
and facilities that, with respect to such health 
plan, are participating providers and facilities. 
‘‘(2) The good faith estimate included in the 
notification received from the provider or facility. 
‘‘(3) A good faith estimate of the amount the 
health plan is responsible for paying for items and 
services included in the estimate described in para-
graph (2). 
‘‘(4) A good faith estimate of the amount of 
any cost-sharing (including with respect to the de-
ductible and any copayment or coinsurance obliga-
tion) for which the participant or beneficiary would 
be responsible for such item or service (as of the 
date of such notification). 
‘‘(5) A good faith estimate of the amount that 
the participant or beneficiary has incurred toward 
meeting the limit of the financial responsibility (in-
cluding with respect to deductibles and out-of-pocket 
maximums) under the health plan (as of the date of 
such notification). 
‘‘(6) In the case such item or service is subject 
to a medical management technique (including con-
current review, prior authorization, and step-therapy 
or fail-first protocols) for coverage under the health 
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114 
plan, a disclaimer that coverage for such item or 
service is subject to such medical management tech-
nique. 
‘‘(7) A disclaimer that the information provided 
in the notification is only an estimate based on the 
items and services reasonably expected, at the time 
of scheduling (or requesting) the item or service, to 
be furnished and is subject to change. 
‘‘(8) A statement that the individual may seek 
such an item or service from a provider that is a 
participating provider or a facility that is a partici-
pating facility and a list of participating facilities, or 
of participating providers, as applicable, who are 
able to furnish such items and services involved. 
‘‘(9) Any other information or disclaimer the 
health plan determines appropriate that is consistent 
with information and disclaimers required under this 
section. 
‘‘(i) COST-SHARING AND PAYMENT FOR SERVICES 
PROVIDED BASED ON RELIANCE ON INCORRECT PRO-
VIDER NETWORK INFORMATION.— 
‘‘(1) IN GENERAL.—For plan years beginning 
on or after January 1, 2022, in the case of an item 
or service furnished to a participant or beneficiary of 
a health plan by a nonparticipating provider or a 
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nonparticipating facility, if such item or service 
would otherwise be covered under such plan if fur-
nished by a participating provider or participating 
facility and if either of the criteria described in para-
graph (2) applies with respect to such participant or 
beneficiary and item or service, the plan— 
‘‘(A) shall not impose on such enrollee a 
cost-sharing amount for such item or service so 
furnished that is greater than the cost-sharing 
amount that would apply under such plan had 
such item or service been furnished by a partici-
pating provider; 
‘‘(B) shall calculate such cost-sharing 
amount as if the contracted rate for such item 
or service furnished by such a participating pro-
vider or facility were equal to— 
‘‘(i) the most recent (as of the date 
such item or service was furnished) con-
tracted rate in effect between such pro-
vider or facility and such plan for such 
item or service furnished under such plan, 
if any; or 
‘‘(ii) if no contracted rate described in 
clause (i) exists, the recognized amount for 
such item or service; 
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116 
‘‘(C) shall pay to such nonparticipating 
provider or facility furnishing such item or serv-
ice to such participant or beneficiary the 
amount by which— 
‘‘(i) if a contracted rate described in 
subparagraph (B)(i) exists, the most re-
cent (as of the date such item or services 
was furnished) such rate; or 
‘‘(ii) if no contracted rate described in 
such subparagraph exists, the out-of-net-
work rate; 
for such items and services exceeds the cost- 
sharing amount imposed under the plan for 
such items and services (as determined in ac-
cordance with subparagraphs (A) and (B)); and 
‘‘(D) shall apply the deductible or out-of- 
pocket maximum, if any, that would apply if 
such services were furnished by a participating 
provider or a participating facility. 
‘‘(2) CRITERIA DESCRIBED.—For purposes of 
paragraph (1), the criteria described in this para-
graph, with respect to an item or service furnished 
to a participant or beneficiary of a health plan by 
a nonparticipating provider or a nonparticipating fa-
cility, are the following: 
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117 
‘‘(A) The participant or beneficiary re-
ceived a notification under subsection (h) with 
respect to such item and service to be furnished 
and such notification provided information that 
the provider was a participating provider or fa-
cility was a participating facility, with respect 
to the plan for furnishing such item or service. 
‘‘(B) A notification was not provided, in 
accordance with subsection (h), to the partici-
pant or beneficiary and the participant or bene-
ficiary requested through the response protocol 
of the plan under subsection (f)(3) information 
on whether the provider was a participating 
provider or facility was a participating facility 
with respect to the plan for furnishing such 
item or service and was informed through such 
protocol that the provider was such a partici-
pating provider or facility was such a partici-
pating facility.’’. 
(c) ERISA AMENDMENTS.—Section 716 of the Em-
ployee Retirement Income Security Act of 1974, as added 
by section 2(c) and amended by sections 3(c) and 5(c), 
is further amended by inserting before subsection (k) the 
following new subsections: 
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118 
‘‘(h) ADVANCED EXPLANATION OF BENEFITS.—Be-
ginning on January 1, 2022, each health plan shall, with 
respect to a notification submitted under section 
1150D(b)(2)(A) of the Social Security Act by a health 
care provider or health care facility, respectively, to the 
health plan for a participant or beneficiary under such 
health plan scheduled to receive an item or service from 
the provider or facility, not later than 1 business day (or, 
in the case such item or service was so scheduled at least 
10 business days before such item or service is to be fur-
nished (or in the case such notification was made pursuant 
to a request by such participant or beneficiary), 3 business 
days) after the date on which the health plan receives such 
notification, provide to the participant or beneficiary 
(through mail or electronic means, as requested by the 
participant or beneficiary) a notification (in clear and un-
derstandable language) including the following: 
‘‘(1) Whether or not the provider or facility is 
a participating provider or a participating facility 
with respect to the health plan with respect to the 
furnishing of such item or service and— 
‘‘(A) in the case the provider or facility is 
a participating provider or facility with respect 
to the health plan with respect to the furnishing 
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119 
of such item or service, the contracted rate 
under such plan for such item or service; and 
‘‘(B) in the case the provider or facility is 
a nonparticipating provider or facility with re-
spect to such plan, a description of how such 
individual may obtain information on providers 
and facilities that, with respect to such health 
plan, are participating providers and facilities. 
‘‘(2) The good faith estimate included in the 
notification received from the provider or facility. 
‘‘(3) A good faith estimate of the amount the 
health plan is responsible for paying for items and 
services included in the estimate described in para-
graph (2). 
‘‘(4) A good faith estimate of the amount of 
any cost-sharing (including with respect to the de-
ductible and any copayment or coinsurance obliga-
tion) for which the participant or beneficiary would 
be responsible for such item or service (as of the 
date of such notification). 
‘‘(5) A good faith estimate of the amount that 
the participant or beneficiary has incurred toward 
meeting the limit of the financial responsibility (in-
cluding with respect to deductibles and out-of-pocket 
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maximums) under the health plan (as of the date of 
such notification). 
‘‘(6) In the case such item or service is subject 
to a medical management technique (including con-
current review, prior authorization, and step-therapy 
or fail-first protocols) for coverage under the health 
plan, a disclaimer that coverage for such item or 
service is subject to such medical management tech-
nique. 
‘‘(7) A disclaimer that the information provided 
in the notification is only an estimate based on the 
items and services reasonably expected, at the time 
of scheduling (or requesting) the item or service, to 
be furnished and is subject to change. 
‘‘(8) A statement that the individual may seek 
such an item or service from a provider that is a 
participating provider or a facility that is a partici-
pating facility and a list of participating facilities, or 
of participating providers, as applicable, who are 
able to furnish such items and services involved. 
‘‘(9) Any other information or disclaimer the 
health plan determines appropriate that is consistent 
with information and disclaimers required under this 
section. 
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121 
‘‘(i) COST-SHARING AND PAYMENT FOR SERVICES 
PROVIDED BASED ON RELIANCE ON INCORRECT PRO-
VIDER NETWORK INFORMATION.— 
‘‘(1) IN GENERAL.—For plan years beginning 
on or after January 1, 2022, in the case of an item 
or service furnished to a participant or beneficiary of 
a health plan by a nonparticipating provider or a 
nonparticipating facility, if such item or service 
would otherwise be covered under such plan if fur-
nished by a participating provider or participating 
facility and if either of the criteria described in para-
graph (2) applies with respect to such participant or 
beneficiary and item or service, the plan— 
‘‘(A) shall not impose on such enrollee a 
cost-sharing amount for such item or service so 
furnished that is greater than the cost-sharing 
amount that would apply under such plan had 
such item or service been furnished by a partici-
pating provider; 
‘‘(B) shall calculate such cost-sharing 
amount as if the contracted rate for such item 
or service furnished by such a participating pro-
vider or facility were equal to— 
‘‘(i) the most recent (as of the date 
such item or service was furnished) con-
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122 
tracted rate in effect between such pro-
vider or facility and such plan for such 
item or service furnished under such plan, 
if any; or 
‘‘(ii) if no contracted rate described in 
clause (i) exists, the recognized amount for 
such item or service; 
‘‘(C) shall pay to such nonparticipating 
provider or facility furnishing such item or serv-
ice to such participant or beneficiary the 
amount by which— 
‘‘(i) if a contracted rate described in 
subparagraph (B)(i) exists, the most re-
cent (as of the date such item or services 
was furnished) such rate; or 
‘‘(ii) if no contracted rate described in 
such subparagraph exists, the out-of-net-
work rate; 
for such items and services exceeds the cost- 
sharing amount imposed under the plan for 
such items and services (as determined in ac-
cordance with subparagraphs (A) and (B)); and 
‘‘(D) shall apply the deductible or out-of- 
pocket maximum, if any, that would apply if 
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123 
such services were furnished by a participating 
provider or a participating facility. 
‘‘(2) CRITERIA DESCRIBED.—For purposes of 
paragraph (1), the criteria described in this para-
graph, with respect to an item or service furnished 
to a participant or beneficiary of a health plan by 
a nonparticipating provider or a nonparticipating fa-
cility, are the following: 
‘‘(A) The participant or beneficiary re-
ceived a notification under subsection (h) with 
respect to such item and service to be furnished 
and such notification provided information that 
the provider was a participating provider or fa-
cility was a participating facility, with respect 
to the plan for furnishing such item or service. 
‘‘(B) A notification was not provided, in 
accordance with subsection (h), to the partici-
pant or beneficiary and the participant or bene-
ficiary requested through the response protocol 
of the plan under subsection (f)(3) information 
on whether the provider was a participating 
provider or facility was a participating facility 
with respect to the plan for furnishing such 
item or service and was informed through such 
protocol that the provider was such a partici-
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124 
pating provider or facility was such a partici-
pating facility.’’. 
SEC. 7. DETERMINATION THROUGH OPEN NEGOTIATION 
AND MEDIATION OF OUT-OF-NETWORK RATES 
TO BE PAID BY HEALTH PLANS. 
(a) PHSA AMENDMENT.—Section 2719A of the Pub-
lic Health Service Act (42 U.S.C. 300gg–19a), as amend-
ed by sections 2(a), 3(a), 5(a), and 6(a), is further amend-
ed by inserting before subsection (k) the following new 
subsection: 
‘‘(j) DETERMINATION OF OUT-OF-NETWORK RATES 
TO BE PAID BY HEALTH PLANS.— 
‘‘(1) DETERMINATION THROUGH OPEN NEGO-
TIATION.— 
‘‘(A) IN
GENERAL.—With respect to an 
item or service furnished in a year by a non-
participating provider or a nonparticipating fa-
cility, with respect to a health plan, in a State 
described in subparagraph (B) of subsection 
(k)(11) with respect to such plan and provider 
or facility, and for which a payment is required 
to be made by the health plan pursuant to sub-
section (b)(1), (e)(1), or (i)(1), the provider or 
facility (as applicable) or plan may, during the 
30-day period beginning on the day the provider 
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125 
or facility receives a response from the plan re-
garding a claim for payment for such item or 
service, initiate open negotiations under this 
paragraph between such provider or facility and 
plan for purposes of determining, during the 
open negotiation period, an amount agreed on 
by such provider or facility, respectively, and 
such plan for payment (including any cost-shar-
ing) for such item or service. For purposes of 
this subsection, the open negotiation period, 
with respect to an item or service, is the 30-day 
period beginning on the date of initiation of the 
negotiations with respect to such item or serv-
ice. 
‘‘(B) EXCHANGE
OF
INFORMATION.—In 
carrying out negotiations initiated under sub-
paragraph (A), with respect to an item or serv-
ice described in such subparagraph furnished in 
a year, not later than the fifth business day of 
the open negotiation period described in such 
subparagraph with respect to such item or serv-
ice— 
‘‘(i) the health plan that is party to 
such negotiations shall notify the provider 
or facility that is party to such negotia-
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126 
tions of the median contracted rate for 
such item or service and year; and 
‘‘(ii) such provider or facility shall no-
tify such health plan of— 
‘‘(I) the median of the total 
amount of reimbursement (including 
any cost-sharing) paid, for the most 
recent year for which information is 
available, to such provider or facility 
for furnishing such item or service to 
a participant, beneficiary, or enrollee 
of a health plan that, at the time such 
item or service was furnished, had a 
contract in effect with such provider 
or facility with respect to the fur-
nishing of such item or service; 
‘‘(II) in the case that information 
described in subclause (I) is not avail-
able, such information as specified by 
the Secretary; and 
‘‘(III) any additional information 
specified by the Secretary. 
‘‘(C) 
ACCESSING
MEDIATED
DISPUTE 
PROCESS IN CASE OF FAILED NEGOTIATIONS.— 
In the case of open negotiations pursuant to 
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127 
subparagraph (A), with respect to an item or 
service, that do not result in a determination of 
an amount of payment for such item or service 
by the last day of the open negotiation period 
described in such subparagraph with respect to 
such item or service, the provider or facility (as 
applicable) or health plan that was party to 
such negotiations may, during the 2-day period 
beginning on the day after such open negotia-
tion period, initiate the mediated dispute proc-
ess under paragraph (2) with respect to such 
item or service. The mediated dispute process 
shall be initiated by a party pursuant to the 
previous sentence by submission to the other 
party and to the Secretary of a notification 
(containing such information as specified by the 
Secretary) and for purposes of this subsection, 
the date of initiation of such process shall be 
the date of such submission or such other date 
specified by the Secretary pursuant to regula-
tions that is not later than the date of receipt 
of such notification by both the other party and 
the Secretary. 
‘‘(2) MEDIATED DISPUTE PROCESS AVAILABLE 
IN CASE OF FAILED OPEN NEGOTIATIONS.— 
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128 
‘‘(A) ESTABLISHMENT.—Not later than 
July 1, 2021, the Secretary, in coordination 
with the Secretary of the Treasury and the Sec-
retary of Labor, shall establish a process (in 
this subsection referred to as the ‘mediated dis-
pute process’) under which, in the case of an 
item or service with respect to which a provider 
or facility (as applicable) or health plan submits 
a notification under paragraph (1)(C) (in this 
subsection referred to as a ‘qualified mediated 
dispute item or service’), an entity selected 
under paragraph (3) determines, subject to sub-
paragraph (B) and in accordance with the suc-
ceeding provisions of this subsection, the 
amount of payment under the health plan for 
such item or service furnished by such provider 
or facility. 
‘‘(B) AUTHORITY TO CONTINUE NEGOTIA-
TIONS.—Under the mediated dispute process, in 
the case that the parties to a determination for 
a qualified mediated dispute item or service 
agree on a payment amount for such item or 
service during such process but before the date 
on which the entity selected with respect to 
such determination under paragraph (3) makes 
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129 
such determination, such amount shall be treat-
ed for purposes of subsection (k)(11)(B) as the 
amount agreed to by such parties for such item 
or service. In the case of an agreement de-
scribed in the previous sentence, the mediated 
dispute process shall provide for a method to 
determine how to allocate between the parties 
to such determination the payment of the com-
pensation of the entity selected with respect to 
such determination. 
‘‘(3) SELECTION
UNDER
MEDIATED
DISPUTE 
PROCESS.—Under the mediated dispute process, the 
Secretary shall, with respect to the determination of 
the amount of payment under this subsection of a 
qualified mediated dispute item or service, provide 
for a method— 
‘‘(A) that allows the parties to such deter-
mination to jointly select, not later than the last 
day of the 3-day period following the date of 
the initiation of the process with respect to such 
item or service, for purposes of making such de-
termination, an entity certified under paragraph 
(7) that— 
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130 
‘‘(i) is not a party to such determina-
tion or an employee or agent of such a 
party; 
‘‘(ii) does not have a material familial, 
financial, or professional relationship with 
such a party; and 
‘‘(iii) does not otherwise have a con-
flict of interest with such a party (as de-
termined by the Secretary); and 
‘‘(B) that requires, in the case such parties 
do not make such selection by such last day, 
the Secretary to, not later than 6 days after 
such date of initiation— 
‘‘(i) select such an entity that satisfies 
clauses (i) through (iii) of subparagraph 
(A); and 
‘‘(ii) provide notification of such selec-
tion to the provider or facility (as applica-
ble) and the health plan party to such de-
termination. 
An entity selected pursuant to the previous sentence 
to make a determination described in such sentence 
shall be referred to in this subsection as the ‘selected 
independent entity’ with respect to such determina-
tion. 
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131 
‘‘(4) TREATMENT OF CONSIDERATION OF MUL-
TIPLE ITEMS AND SERVICES.— 
‘‘(A) IN GENERAL.—Under the mediated 
dispute process, the Secretary shall specify cri-
teria under which multiple qualified mediated 
dispute items and services are permitted to be 
considered jointly as part of a single determina-
tion by an entity for purposes of encouraging 
the efficiency (including minimizing costs) of 
the mediated dispute process. Such items and 
services may be so considered only if— 
‘‘(i) such items and services to be in-
cluded in such determination are furnished 
by the same provider or facility; 
‘‘(ii) payment for such items and serv-
ices is required to be made by the same 
health plan; and 
‘‘(iii) such items and services are re-
lated to the treatment of a similar condi-
tion. 
‘‘(B) TREATMENT
OF
BUNDLED
PAY-
MENTS.—In carrying out subparagraph (A), the 
Secretary shall provide that, in the case of 
items and services which are included by a pro-
vider or facility as part of a bundled payment, 
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132 
such items and services included in such bun-
dled payment may be part of a single deter-
mination under this subsection. 
‘‘(C) WAIVER OF DEADLINES.—For pur-
poses of permitting joint consideration of quali-
fied mediated dispute items and services as part 
of a single determination under the criteria 
specified pursuant to subparagraph (A), the 
Secretary may waive any deadline specified in 
this subsection. 
‘‘(5) DETERMINATION OF PAYMENT AMOUNT.— 
‘‘(A) IN
GENERAL.—Not later than 30 
days after the date of initiation of the mediated 
dispute resolution, with respect to a qualified 
mediated dispute item or service, the selected 
independent entity with respect to a determina-
tion under this subsection for such item or serv-
ice shall— 
‘‘(i) taking into account only the con-
siderations 
specified 
in 
subparagraph 
(C)(i), select one of the offers submitted 
under subparagraph (B) to be the amount 
of payment for such item or service deter-
mined under this subsection for purposes 
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of subsection (b)(1), (e)(1), or (i)(1), as 
applicable; and 
‘‘(ii) notify the provider or facility and 
the health plan party to such determina-
tion of the offer selected under clause (i). 
‘‘(B) SUBMISSION OF OFFERS.—Not later 
than 10 days after the date of initiation of the 
mediated dispute resolution with respect to a 
determination for a qualified mediated dispute 
item or service, the provider or facility and the 
health plan party to such determination shall 
each submit to the selected independent enti-
ty— 
‘‘(i) an offer for a payment amount 
under for such item or service furnished by 
such provider or facility; 
‘‘(ii) information relating to such 
offer; and 
‘‘(iii) such other information as re-
quested by the selected independent entity. 
‘‘(C) CONSIDERATIONS.— 
‘‘(i) IN
GENERAL.—For purposes of 
subparagraph (A), the considerations spec-
ified in this subparagraph, with respect to 
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134 
a determination for a qualified mediated 
dispute item or service, are the following: 
‘‘(I) The median contracted rate 
for such item or service. 
‘‘(II) Subject to clause (ii), infor-
mation that is submitted pursuant to 
subparagraph (B). 
‘‘(ii) TREATMENT OF CERTAIN CON-
SIDERATIONS.—In making a determination 
with respect to a qualified mediated dis-
pute item or service pursuant to subpara-
graph (A)(i), a selected independent entity 
may not take into account usual and cus-
tomary charges for the item or service nor 
charges billed by the provider or facility for 
the item or service. 
‘‘(6) SELECTED
INDEPENDENT
ENTITY
COM-
PENSATION.— 
‘‘(A) IN GENERAL.—Not later than 5 days 
after receiving a notification described in para-
graph (5)(A)(ii) from a selected independent 
entity with respect to the determination of a 
payment amount for a qualified mediated dis-
pute item or service, the party to such deter-
mination whose offer submitted under para-
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graph (5)(B) was not selected by the entity 
shall pay to such entity a fee in compensation 
for the services of such entity in accordance 
with the guidelines on such compensation estab-
lished by the Secretary under subparagraph 
(B). 
‘‘(B) GUIDELINES
ON
COMPENSATION.— 
For purposes of subparagraph (A), the Sec-
retary shall establish guidelines with respect to 
the compensation of a selected independent en-
tity for the services of such entity with respect 
to determinations under the mediated dispute 
process. Such guidelines shall provide that such 
compensation reimburses the entity for at least 
the costs of such entity in performing the duties 
of the entity under the mediated dispute proc-
ess. 
‘‘(7) CERTIFICATION OF ENTITIES.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
establish or recognize a process to certify (in-
cluding recertification of) entities under this 
paragraph. Such process shall ensure that an 
entity so certified— 
‘‘(i) has (directly or through contracts 
or other arrangements) sufficient medical, 
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legal, and other expertise and sufficient 
staffing to make determinations described 
in paragraph (2) on a timely basis; 
‘‘(ii) is not— 
‘‘(I) a health plan, provider, or 
facility; 
‘‘(II) an affiliate or a subsidiary 
of a health plan, provider, or facility; 
or 
‘‘(III) an affiliate or subsidiary of 
a professional or trade association of 
health plans or of providers or facili-
ties; 
‘‘(iii) carries out the responsibilities of 
such an entity in accordance with this sub-
section; 
‘‘(iv) meets appropriate indicators of 
fiscal integrity; 
‘‘(v) maintains the confidentiality (in 
accordance with regulations promulgated 
by the Secretary) of individually identifi-
able health information obtained in the 
course of conducting such determinations; 
‘‘(vi) does not under the mediated dis-
pute process carry out any determination 
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with respect to which the entity would not 
pursuant to clause (i), (ii), or (iii) of para-
graph (3)(A) be eligible for selection; and 
‘‘(vii) meets such other requirements 
as determined appropriate by the Sec-
retary. 
‘‘(B) PERIOD OF CERTIFICATION.—Subject 
to subparagraph (C), each certification (includ-
ing a recertification) of an entity under the 
process described in subparagraph (A) shall be 
for a 5-year period. 
‘‘(C) REVOCATION.—A certification of an 
entity under this paragraph may be revoked 
under the process described in subparagraph 
(A) if the entity has a pattern or practice of 
noncompliance with any of the requirements de-
scribed in such subparagraph. 
‘‘(D) PETITION
FOR
DENIAL
OR
WITH-
DRAWAL.—The process described in subpara-
graph (A) shall ensure that an individual, pro-
vider, facility, or health plan may petition for a 
denial of a certification or a revocation of a cer-
tification with respect to an entity under this 
paragraph for failure of meeting a requirement 
of this subsection. 
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