I 
110TH CONGRESS 
1ST SESSION 
H. R. 979 
To amend title I of the Employee Retirement Income Security Act of 1974, 
title XXVII of the Public Health Service Act, and the Internal Revenue 
Code of 1986 to protect consumers in managed care plans and other 
health coverage. 
IN THE HOUSE OF REPRESENTATIVES 
FEBRUARY 12, 2007 
Mr. NORWOOD (for himself and Mr. DINGELL) introduced the following bill; 
which was referred to the Committee on Energy and Commerce, and in 
addition to the Committees on Education and Labor and Ways and 
Means, for a period to be subsequently determined by the Speaker, in 
each case for consideration of such provisions as fall within the jurisdic-
tion of the committee concerned 
A BILL 
To amend title I of the Employee Retirement Income Secu-
rity Act of 1974, title XXVII of the Public Health Serv-
ice Act, and the Internal Revenue Code of 1986 to pro-
tect consumers in managed care plans and other health 
coverage. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
VerDate Aug 31 2005 
22:40 Feb 28, 2007
Jkt 059200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6201
E:\BILLS\H979.IH
H979
pwalker on PROD1PC71 with BILLS
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Bipartisan Consensus Managed Care Improvement Act 
of 2007’’. 
(b) TABLE OF CONTENTS.—The table of contents of 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
TITLE I—IMPROVING MANAGED CARE 
Subtitle A—Grievance and Appeals 
Sec. 101. Utilization review activities. 
Sec. 102. Internal appeals procedures. 
Sec. 103. External appeals procedures. 
Sec. 104. Establishment of a grievance process. 
Subtitle B—Access to Care 
Sec. 111. Consumer choice option. 
Sec. 112. Choice of health care professional. 
Sec. 113. Access to emergency care. 
Sec. 114. Access to specialty care. 
Sec. 115. Access to obstetrical and gynecological care. 
Sec. 116. Access to pediatric care. 
Sec. 117. Continuity of care. 
Sec. 118. Access to needed prescription drugs. 
Sec. 119. Coverage for individuals participating in approved clinical trials. 
Subtitle C—Access to Information 
Sec. 121. Patient access to information. 
Subtitle D—Protecting the Doctor-Patient Relationship 
Sec. 131. Prohibition of interference with certain medical communications. 
Sec. 132. Prohibition of discrimination against providers based on licensure. 
Sec. 133. Prohibition against improper incentive arrangements. 
Sec. 134. Payment of claims. 
Sec. 135. Protection for patient advocacy. 
Subtitle E—Definitions 
Sec. 151. Definitions. 
Sec. 152. Preemption; State flexibility; construction. 
Sec. 153. Exclusions. 
Sec. 154. Coverage of limited scope plans. 
VerDate Aug 31 2005 
22:40 Feb 28, 2007
Jkt 059200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6211
E:\BILLS\H979.IH
H979
pwalker on PROD1PC71 with BILLS
Sec. 155. Regulations. 
TITLE II—APPLICATION OF QUALITY CARE STANDARDS TO 
GROUP HEALTH PLANS AND HEALTH INSURANCE COVERAGE 
UNDER THE PUBLIC HEALTH SERVICE ACT 
Sec. 201. Application to group health plans and group health insurance cov-
erage. 
Sec. 202. Application to individual health insurance coverage. 
TITLE III—AMENDMENTS TO THE EMPLOYEE RETIREMENT 
INCOME SECURITY ACT OF 1974 
Sec. 301. Application of patient protection standards to group health plans and 
group health insurance coverage under the Employee Retire-
ment Income Security Act of 1974. 
Sec. 302. ERISA preemption not to apply to certain actions involving health in-
surance policyholders. 
TITLE IV—APPLICATION TO GROUP HEALTH PLANS UNDER THE 
INTERNAL REVENUE CODE OF 1986 
Sec. 401. Amendments to the Internal Revenue Code of 1986. 
TITLE V—EFFECTIVE DATES; COORDINATION IN 
IMPLEMENTATION 
Sec. 501. Effective dates. 
Sec. 502. Coordination in implementation. 
TITLE VI—HEALTH CARE PAPERWORK SIMPLIFICATION 
Sec. 601. Health care paperwork simplification. 
TITLE I—IMPROVING MANAGED 
CARE 
Subtitle A—Grievance and Appeals 
SEC. 101. UTILIZATION REVIEW ACTIVITIES. 
(a) COMPLIANCE WITH REQUIREMENTS.— 
(1) IN GENERAL.—A group health plan, and a 
health insurance issuer that provides health insur-
ance coverage, shall conduct utilization review activi-
ties in connection with the provision of benefits 
under such plan or coverage only in accordance with 
VerDate Aug 31 2005 
22:40 Feb 28, 2007
Jkt 059200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6201
E:\BILLS\H979.IH
H979
pwalker on PROD1PC71 with BILLS
a utilization review program that meets the require-
ments of this section. 
(2) USE OF OUTSIDE AGENTS.—Nothing in this 
section shall be construed as preventing a group 
health plan or health insurance issuer from arrang-
ing through a contract or otherwise for persons or 
entities to conduct utilization review activities on be-
half of the plan or issuer, so long as such activities 
are conducted in accordance with a utilization review 
program that meets the requirements of this section. 
(3) UTILIZATION REVIEW DEFINED.—For pur-
poses of this section, the terms ‘‘utilization review’’ 
and ‘‘utilization review activities’’ mean procedures 
used to monitor or evaluate the use or coverage, 
clinical necessity, appropriateness, efficacy, or effi-
ciency of health care services, procedures or settings, 
and includes prospective review, concurrent review, 
second opinions, case management, discharge plan-
ning, or retrospective review. 
(b) WRITTEN POLICIES AND CRITERIA.— 
(1) WRITTEN POLICIES.—A utilization review 
program shall be conducted consistent with written 
policies and procedures that govern all aspects of the 
program. 
(2) USE OF WRITTEN CRITERIA.— 
VerDate Aug 31 2005 
22:40 Feb 28, 2007
Jkt 059200
PO 00000
Frm 00004
Fmt 6652
Sfmt 6201
E:\BILLS\H979.IH
H979
pwalker on PROD1PC71 with BILLS
(A) IN GENERAL.—Such a program shall 
utilize written clinical review criteria developed 
with input from a range of appropriate actively 
practicing health care professionals, as deter-
mined by the plan, pursuant to the program. 
Such criteria shall include written clinical re-
view criteria that are based on valid clinical evi-
dence where available and that are directed spe-
cifically at meeting the needs of at-risk popu-
lations and covered individuals with chronic 
conditions or severe illnesses, including gender- 
specific criteria and pediatric-specific criteria 
where available and appropriate. 
(B) CONTINUING USE OF STANDARDS IN 
RETROSPECTIVE
REVIEW.—If a health care 
service has been specifically pre-authorized or 
approved for an enrollee under such a program, 
the program shall not, pursuant to retrospective 
review, revise or modify the specific standards, 
criteria, or procedures used for the utilization 
review for procedures, treatment, and services 
delivered to the enrollee during the same course 
of treatment. 
(C) REVIEW OF SAMPLE OF CLAIMS DENI-
ALS.—Such a program shall provide for an 
VerDate Aug 31 2005 
22:40 Feb 28, 2007
Jkt 059200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H979.IH
H979
pwalker on PROD1PC71 with BILLS
evaluation of the clinical appropriateness of at 
least a sample of denials of claims for benefits. 
(c) CONDUCT OF PROGRAM ACTIVITIES.— 
(1) ADMINISTRATION BY HEALTH CARE PRO-
FESSIONALS.—A utilization review program shall be 
administered by qualified health care professionals 
who shall oversee review decisions. 
(2) USE
OF
QUALIFIED, INDEPENDENT
PER-
SONNEL.— 
(A) IN
GENERAL.—A utilization review 
program shall provide for the conduct of utiliza-
tion review activities only through personnel 
who are qualified and have received appropriate 
training in the conduct of such activities under 
the program. 
(B) PROHIBITION
OF
CONTINGENT
COM-
PENSATION ARRANGEMENTS.—Such a program 
shall not, with respect to utilization review ac-
tivities, permit or provide compensation or any-
thing of value to its employees, agents, or con-
tractors in a manner that encourages denials of 
claims for benefits. 
(C) PROHIBITION OF CONFLICTS.—Such a 
program shall not permit a health care profes-
sional who is providing health care services to 
VerDate Aug 31 2005 
22:40 Feb 28, 2007
Jkt 059200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H979.IH
H979
pwalker on PROD1PC71 with BILLS
an individual to perform utilization review ac-
tivities in connection with the health care serv-
ices being provided to the individual. 
(3) ACCESSIBILITY OF REVIEW.—Such a pro-
gram shall provide that appropriate personnel per-
forming utilization review activities under the pro-
gram, including the utilization review administrator, 
are reasonably accessible by toll-free telephone dur-
ing normal business hours to discuss patient care 
and allow response to telephone requests, and that 
appropriate provision is made to receive and respond 
promptly to calls received during other hours. 
(4) LIMITS ON FREQUENCY.—Such a program 
shall not provide for the performance of utilization 
review activities with respect to a class of services 
furnished to an individual more frequently than is 
reasonably required to assess whether the services 
under review are medically necessary or appropriate. 
(d) DEADLINE FOR DETERMINATIONS.— 
(1) PRIOR AUTHORIZATION SERVICES.— 
(A) IN GENERAL.—Except as provided in 
paragraph (2), in the case of a utilization re-
view activity involving the prior authorization of 
health care items and services for an individual, 
the utilization review program shall make a de-
VerDate Aug 31 2005 
22:40 Feb 28, 2007
Jkt 059200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\H979.IH
H979
pwalker on PROD1PC71 with BILLS
termination concerning such authorization, and 
provide notice of the determination to the indi-
vidual or the individual’s designee and the indi-
vidual’s health care provider by telephone and 
in printed form, as soon as possible in accord-
ance with the medical exigencies of the case, 
and in no event later than the deadline specified 
in subparagraph (B). 
(B) DEADLINE.— 
(i) IN GENERAL.—Subject to clauses 
(ii) and (iii), the deadline specified in this 
subparagraph is 14 days after the date of 
receipt of the request for prior authoriza-
tion. 
(ii) EXTENSION
PERMITTED
WHERE 
NOTICE OF ADDITIONAL INFORMATION RE-
QUIRED.—If a utilization review pro-
gram— 
(I) receives a request for a prior 
authorization, 
(II) determines that additional 
information is necessary to complete 
the review and make the determina-
tion on the request, and 
VerDate Aug 31 2005 
22:40 Feb 28, 2007
Jkt 059200
PO 00000
Frm 00008
Fmt 6652
Sfmt 6201
E:\BILLS\H979.IH
H979
pwalker on PROD1PC71 with BILLS
(III) notifies the requester, not 
later than 5 business days after the 
date of receiving the request, of the 
need for such specified additional in-
formation, 
the deadline specified in this subparagraph 
is 14 days after the date the program re-
ceives the specified additional information, 
but in no case later than 28 days after the 
date of receipt of the request for the prior 
authorization. This clause shall not apply 
if the deadline is specified in clause (iii). 
(iii) EXPEDITED CASES.—In the case 
of 
a 
situation 
described 
in 
section 
102(c)(1)(A), the deadline specified in this 
subparagraph is 72 hours after the time of 
the request for prior authorization. 
(2) ONGOING CARE.— 
(A) CONCURRENT REVIEW.— 
(i) IN GENERAL.—Subject to subpara-
graph (B), in the case of a concurrent re-
view of ongoing care (including hospitaliza-
tion), which results in a termination or re-
duction of such care, the plan must provide 
by telephone and in printed form notice of 
VerDate Aug 31 2005 
22:40 Feb 28, 2007
Jkt 059200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H979.IH
H979
pwalker on PROD1PC71 with BILLS
the concurrent review determination to the 
individual or the individual’s designee and 
the individual’s health care provider as 
soon as possible in accordance with the 
medical exigencies of the case, with suffi-
cient time prior to the termination or re-
duction to allow for an appeal under sec-
tion 102(c)(1)(A) to be completed before 
the termination or reduction takes effect. 
(ii) CONTENTS OF NOTICE.—Such no-
tice shall include, with respect to ongoing 
health care items and services, the number 
of ongoing services approved, the new total 
of approved services, the date of onset of 
services, and the next review date, if any, 
as well as a statement of the individual’s 
rights to further appeal. 
(B) EXCEPTION.—Subparagraph (A) shall 
not be interpreted as requiring plans or issuers 
to provide coverage of care that would exceed 
the coverage limitations for such care. 
(3) PREVIOUSLY PROVIDED SERVICES.—In the 
case of a utilization review activity involving retro-
spective review of health care services previously pro-
vided for an individual, the utilization review pro-
VerDate Aug 31 2005 
22:40 Feb 28, 2007
Jkt 059200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\H979.IH
H979
pwalker on PROD1PC71 with BILLS
gram shall make a determination concerning such 
services, and provide notice of the determination to 
the individual or the individual’s designee and the 
individual’s health care provider by telephone and in 
printed form, within 30 days of the date of receipt 
of information that is reasonably necessary to make 
such determination, but in no case later than 60 
days after the date of receipt of the claim for bene-
fits. 
(4) FAILURE TO MEET DEADLINE.—In a case 
in which a group health plan or health insurance 
issuer fails to make a determination on a claim for 
benefit under paragraph (1), (2)(A), or (3) by the 
applicable deadline established under the respective 
paragraph, the failure shall be treated under this 
subtitle as a denial of the claim as of the date of the 
deadline. 
(5) REFERENCE TO SPECIAL RULES FOR EMER-
GENCY SERVICES, MAINTENANCE CARE, AND POST- 
STABILIZATION CARE.—For waiver of prior author-
ization requirements in certain cases involving emer-
gency services and maintenance care and post-sta-
bilization care, see subsections (a)(1) and (b) of sec-
tion 113, respectively. 
VerDate Aug 31 2005 
22:40 Feb 28, 2007
Jkt 059200
PO 00000
Frm 00011
Fmt 6652
Sfmt 6201
E:\BILLS\H979.IH
H979
pwalker on PROD1PC71 with BILLS
(e) NOTICE OF DENIALS OF CLAIMS FOR BENE-
FITS.— 
(1) IN GENERAL.—Notice of a denial of claims 
for benefits under a utilization review program shall 
be provided in printed form and written in a manner 
calculated to be understood by the participant, bene-
ficiary, or enrollee and shall include— 
(A) the reasons for the denial (including 
the clinical rationale); 
(B) instructions on how to initiate an ap-
peal under section 102; and 
(C) notice of the availability, upon request 
of the individual (or the individual’s designee) 
of the clinical review criteria relied upon to 
make such denial. 
(2) SPECIFICATION OF ANY ADDITIONAL INFOR-
MATION.—Such a notice shall also specify what (if 
any) additional necessary information must be pro-
vided to, or obtained by, the person making the de-
nial in order to make a decision on such an appeal. 
(f) CLAIM FOR BENEFITS AND DENIAL OF CLAIM 
FOR BENEFITS DEFINED.—For purposes of this subtitle: 
(1) CLAIM FOR BENEFITS.—The term ‘‘claim 
for benefits’’ means any request for coverage (in-
cluding authorization of coverage), for eligibility, or 
VerDate Aug 31 2005 
22:40 Feb 28, 2007
Jkt 059200
PO 00000
Frm 00012
Fmt 6652
Sfmt 6201
E:\BILLS\H979.IH
H979
pwalker on PROD1PC71 with BILLS
for payment in whole or in part, for an item or serv-
ice under a group health plan or health insurance 
coverage. 
(2) DENIAL
OF
CLAIM
FOR
BENEFITS.—The 
term ‘‘denial’’ means, with respect to a claim for 
benefits, means a denial, or a failure to act on a 
timely basis upon, in whole or in part, the claim for 
benefits and includes a failure to provide benefits 
(including items and services) required to be pro-
vided under this title. 
SEC. 102. INTERNAL APPEALS PROCEDURES. 
(a) RIGHT OF REVIEW.— 
(1) IN GENERAL.—Each group health plan, and 
each health insurance issuer offering health insur-
ance coverage— 
(A) shall provide adequate notice in writ-
ing to any participant or beneficiary under such 
plan, or enrollee under such coverage, whose 
claim for benefits under the plan or coverage 
has been denied (within the meaning of section 
101(f)(2)), setting forth the specific reasons for 
such denial of claim for benefits and rights to 
any further review or appeal, written in a man-
ner calculated to be understood by the partici-
pant, beneficiary, or enrollee; and 
VerDate Aug 31 2005 
22:40 Feb 28, 2007
Jkt 059200
PO 00000
Frm 00013
Fmt 6652
Sfmt 6201
E:\BILLS\H979.IH
H979
pwalker on PROD1PC71 with BILLS
(B) shall afford such a participant, bene-
ficiary, or enrollee (and any provider or other 
person acting on behalf of such an individual 
with the individual’s consent or without such 
consent if the individual is medically unable to 
provide such consent) who is dissatisfied with 
such a denial of claim for benefits a reasonable 
opportunity (of not less than 180 days) to re-
quest and obtain a full and fair review by a 
named fiduciary (with respect to such plan) or 
named appropriate individual (with respect to 
such coverage) of the decision denying the 
claim. 
(2) TREATMENT OF ORAL REQUESTS.—The re-
quest for review under paragraph (1)(B) may be 
made orally, but, in the case of an oral request, shall 
be followed by a request in writing. 
(b) INTERNAL REVIEW PROCESS.— 
(1) CONDUCT OF REVIEW.— 
(A) IN GENERAL.—A review of a denial of 
claim under this section shall be made by an in-
dividual who— 
(i) in a case involving medical judg-
ment, shall be a physician or, in the case 
of limited scope coverage (as defined in 
VerDate Aug 31 2005 
22:40 Feb 28, 2007
Jkt 059200
PO 00000
Frm 00014
Fmt 6652
Sfmt 6201
E:\BILLS\H979.IH
H979
pwalker on PROD1PC71 with BILLS