I 
118TH CONGRESS 
1ST SESSION H. R. 5213 
To ensure that prior authorization medical decisions under Medicare are 
determined by physicians. 
IN THE HOUSE OF REPRESENTATIVES 
AUGUST 15, 2023 
Mr. GREEN of Tennessee introduced the following bill; which was referred to 
the Committee on Ways and Means, and in addition to the Committee 
on Energy and Commerce, for a period to be subsequently determined by 
the Speaker, in each case for consideration of such provisions as fall with-
in the jurisdiction of the committee concerned 
A BILL 
To ensure that prior authorization medical decisions under 
Medicare are determined by physicians. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Reducing Medically 
Unnecessary Delays in Care Act of 2023’’. 
SEC. 2. DEFINITIONS. 
In this Act: 
(1) ADVERSE DETERMINATION.—The term ‘‘ad-
verse determination’’ means a decision by a medicare 
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administrative contractor, Medicare Advantage plan, 
or prescription drug plan that administers prior au-
thorization programs under the Medicare program 
under title XVIII of the Social Security Act or such 
plan that the health care services furnished or pro-
posed to be furnished to an individual entitled to 
benefits or enrolled under the Medicare program are 
not medically necessary, or are experimental or in-
vestigational; and benefit coverage under such pro-
gram or plan for such services is therefore denied, 
reduced, or terminated. 
(2) AUTHORIZATION.—The term ‘‘authoriza-
tion’’ means a determination by a medicare adminis-
trative contractor, Medicare Advantage plan, or pre-
scription drug plan that administers prior authoriza-
tion programs under the Medicare program under 
title XVIII of the Social Security Act or such plan 
that a health care service has been reviewed and, 
based on the information provided, satisfies the utili-
zation review entity’s requirements for medical ne-
cessity and appropriateness and that payment will 
be made under the Medicare program under title 
XVIII of the Social Security Act or such plan for 
that health care service. 
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(3) CLINICAL
CRITERIA.—The term ‘‘clinical 
criteria’’ means the written policies, written screen-
ing procedures, drug formularies, or lists of covered 
drugs, decision rules, decision abstracts, clinical pro-
tocols, practice guidelines, and medical protocols 
used by a medicare administrative contractor, Medi-
care Advantage plan, or prescription drug plan to 
determine the necessity and appropriateness of 
health care services. 
(4) FINAL
ADVERSE
DETERMINATION.—The 
term ‘‘final adverse determination’’ means an ad-
verse determination that has been upheld by a medi-
care administrative contractor, Medicare Advantage 
plan, or prescription drug plan at the completion of 
the contractor’s appeals process. 
(5) HEALTH CARE SERVICE.—The term ‘‘health 
care service’’ means a health care item, service, pro-
cedure, treatment, or prescription drug provided by 
a facility licensed in the State involved or provided 
by a doctor of medicine, a doctor of osteopathy, or 
a health care professional licensed in such State. 
(6) MEDICALLY
NECESSARY
HEALTH
CARE 
SERVICE.—The term ‘‘medically necessary health 
care services’’ means health care services that a pru-
dent physician would provide to a patient for the 
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purpose of preventing, diagnosing, or treating an ill-
ness, injury, disease, or its symptoms in a manner 
that is— 
(A) in accordance with generally accepted 
standards of medical practice; 
(B) clinically appropriate in terms of type, 
frequency, extent, site, and duration; and 
(C) not primarily for the economic benefit 
of the health plans and purchasers or for the 
convenience of the patient, treating physician, 
or other health care provider. 
(7) 
MEDICARE
ADMINISTRATIVE
CON-
TRACTOR.—The term ‘‘medicare administrative con-
tractor’’ means a medicare administrative contractor 
with a contract under section 1874A of the Social 
Security Act (42 U.S.C. 1395kk–1). 
(8) MEDICARE ADVANTAGE PLAN.—The term 
‘‘Medicare Advantage plan’’ means a Medicare Ad-
vantage plan under part C of title XVIII of the So-
cial Security Act. 
(9) 
PREAUTHORIZATION.—The 
term 
‘‘preauthorization’’— 
(A) means the process by which a medicare 
administrative contractor, Medicare Advantage 
plan, or prescription drug plan determines the 
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medical necessity or medical appropriateness of 
health care services for which benefits are oth-
erwise provided under the Medicare program 
under title XVIII of the Social Security Act or 
such plan prior to the rendering of such health 
care services, including preadmission review, 
pretreatment review, utilization, and case man-
agement; and 
(B) includes any requirement that a pa-
tient or health care provider notify the Centers 
for Medicare & Medicaid Services prior to pro-
viding a health care service. 
(10) PRESCRIPTION
DRUG
PLAN.—The term 
‘‘prescription drug plan’’ means a prescription drug 
plan under part D of title XVIII of the Social Secu-
rity Act. 
SEC. 3. CONTRACT REQUIREMENTS FOR PRIOR AUTHOR-
IZATION MEDICAL DECISIONS FOR MEDI-
CARE 
ADMINISTRATIVE 
CONTRACTORS, 
MEDICARE ADVANTAGE PLANS, AND PRE-
SCRIPTION DRUG PLANS. 
Any contract that applies on or after the date that 
is 90 days after the date of the enactment of this Act, 
between the Secretary of Health and Human Services and 
a medicare administrative contractor under section 1874A 
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of the Social Security Act, a Medicare Advantage organi-
zation under section 1857 of such Act with respect to the 
offering of a Medicare Advantage plan, or a PDP sponsor 
under section 1860D–12 of such Act with respect to the 
offering of a prescription drug plan shall require such 
medicare administrative contractor, Medicare Advantage 
plan, or prescription drug plan, respectively, to comply 
with each of the following requirements: 
(1) MEDICAL
NECESSITY.—Any restriction, 
preauthorization, adverse determination, or final ad-
verse determination that the medicare administrative 
contractor, Medicare Advantage plan, or prescription 
drug plan, respectively, places on the provision of a 
health care service for the purposes of coverage or 
payment of such service under the Medicare pro-
gram under title XVIII of such Act, or under such 
plan, shall be based on the medical necessity or ap-
propriateness of such service and on written clinical 
criteria. 
(2) EVIDENCE-BASED STANDARDS.—If no inde-
pendently developed evidence-based standards exist 
for a particular health care service, the medicare ad-
ministrative contractor, Medicare Advantage plan, or 
prescription drug plan, respectively, may not deny 
coverage of the health care service based solely on 
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the grounds that the health care service does not 
meet an evidence-based standard. 
(3) INPUT FROM PHYSICIANS.—Prior to estab-
lishing, or substantially or materially altering, writ-
ten clinical criteria for purpose of preauthorization 
review, the medicare administrative contractor, 
Medicare Advantage plan, or prescription drug plan, 
respectively, shall obtain input from actively prac-
ticing physicians within the service area where the 
written clinical criteria are to be employed. Such 
physicians must represent major areas of specialty 
and be certified by the boards of the American 
Board of Medical Specialties. The medicare adminis-
trative contractor, Medicare Advantage plan, or pre-
scription drug plan shall seek input from physicians 
who are not employees of the medicare administra-
tive contractor, Medicare Advantage plan, or pre-
scription drug plan. 
(4) WRITTEN CLINICAL CRITERIA.—The medi-
care administrative contractor, Medicare Advantage 
plan, or prescription drug plan, respectively, shall 
apply written clinical criteria for the purpose of 
preauthorization review consistently. Such written 
clinical criteria must— 
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(A) be based on nationally recognized 
standards; 
(B) be developed in accordance with the 
current standards of national accreditation enti-
ties; 
(C) reflect community standards of care; 
(D) ensure quality of care and access to 
needed health care services; 
(E) be evidence based; 
(F) be sufficiently flexible to allow devi-
ations from norms when justified on case-by- 
case bases; and 
(G) be evaluated and updated if necessary 
at least annually. 
(5) WEBSITE POSTING.—The medicare adminis-
trative contractor, Medicare Advantage plan, or pre-
scription drug plan, respectively, shall make any cur-
rent preauthorization requirements and restrictions 
readily accessible on its website to subscribers, 
health care providers, and the general public. This 
includes the written clinical criteria. Such require-
ments must be described in detail but also in easily 
understandable language. 
(6) NOTICE
REQUIRED
FOR
NEW
REQUIRE-
MENTS OR RESTRICTIONS.—If the medicare adminis-
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trative contractor, Medicare Advantage plan, or pre-
scription drug plan, respectively, decides to imple-
ment a new preauthorization requirement or restric-
tion, or amend an existing requirement or restric-
tion, the medicare administrative contractor, Medi-
care Advantage plan, or prescription drug plan shall 
provide contracted health care providers written no-
tice of the new or amended requirement or amend-
ment no less than 60 days before the requirement or 
restriction is implemented and shall ensure that the 
new or amended requirement has been updated on 
the medicare administrative contractor, Medicare 
Advantage plan, or prescription drug plan’s website. 
(7) AVAILABILITY OF DETERMINATIONS.—The 
medicare administrative contractor, Medicare Advan-
tage plan, or prescription drug plan, respectively, 
utilizing preauthorization shall make statistics avail-
able regarding preauthorization approvals and deni-
als for coverage or payment of health care services 
under the Medicare program under title XVIII of 
the Social Security Act or such plan on their website 
in a readily accessible format. The medicare admin-
istrative contractor, Medicare Advantage plan, or 
prescription drug plan shall include categories for— 
(A) physician specialty; 
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(B) medication or diagnostic test/proce-
dure; 
(C) indication offered; and 
(D) reason for denial. 
(8) DETERMINATIONS MADE BY PHYSICIANS.— 
The medicare administrative contractor, Medicare 
Advantage plan, or prescription drug plan, respec-
tively, shall ensure that all preauthorizations and ad-
verse determinations are made by a physician who 
possesses a current and valid non-restricted license 
to practice medicine in a State, and must be board 
certified or eligible in the same specialty as the 
health care provider who typically manages the med-
ical condition or disease or provides the health care 
service. The physician must make the adverse deter-
mination under the clinical direction of one of the 
medicare administrative contractor’s, Medicare Ad-
vantage plan’s, or prescription drug plan’s medical 
directors who is responsible for the provision of 
health care services and who is licensed in such 
State. 
Æ 
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