Social Security Act §1833

(A)The determinationthat an eligible professional is a qualifying APM participant underparagraph (2) and the determination that an entity is an eligiblealternative payment entity under paragraph (3)(D).(B)The determinationof the amount of the 5 percent payment incentive under paragraph (1)(A),including any estimation as part of such determination.[141](z)MedicalReview of Spinal Subluxation Services.[142](1)In general.The Secretary shall implement a process for the medical review(as described in paragraph (2)) of treatment by a chiropractor describedin section 1861(r)(5) by meansof manual manipulation of the spine to correct a subluxation (as describedin such section) of an individual who is enrolled under this partand apply such process to such services furnished on or after January1, 2017, focusing on services such as(A)servicesfurnished by a such a chiropractor whose pattern of billing is aberrantcompared to peers; and(B)servicesfurnished by such a chiropractor who, in a prior period, has a servicesdenial percentage in the 85th percentile or greater, taking into considerationthe extent that service denials are overturned on appeal.(2)Medicalreview.(A)Prior authorization medical review.(i)Ingeneral.Subject to clause (ii), theSecretary shall use prior authorization medical review for servicesdescribed in paragraph (1) that are furnished to an individual bya chiropractor described in section 1861(r)(5) that are part of an episode of treatment that includesmore than 12 services. For purposes of the preceding sentence, anepisode of treatment shall be determined by the underlying cause thatjustifies the need for services, such as a diagnosis code.(ii)Endingapplication of prior authorization medical review.The Secretary shall end the application of prior authorizationmedical review under clause (i) to services described in paragraph(1) by such a chiropractor if the Secretary determines that the chiropractorhas a low denial rate under such prior authorization medical review.The Secretary may subsequently reapply prior authorization medicalreview to such chiropractor if the Secretary determines it to be appropriateand the chiropractor has, in the time period subsequent to the determinationby the Secretary of a low denial rate with respect to the chiropractor,furnished such services described in paragraph (1).(iii)Early request for prior authorization review permitted.Nothing in this subsection shall be construed to prevent sucha chiropractor from requesting prior authorization for services describedin paragraph (1) that are to be furnished to an individual beforethe chiropractor furnishes the twelfth such service to such individualfor an episode of treatment.(B)Type of review.The Secretary may usepre- payment review or post-payment review of services described insection 1861(r)(5) that arenot subject to prior authorization medical review under subparagraph(A).(C)Relationship to law enforcement activities.The Secretary may determine that medical review under this subsectiondoes not apply in the case where potential fraud may be involved.(3)No paymentwithout prior authorization.With respectto a service described in paragraph (1) for which prior authorizationmedical review under this subsection applies, the following shallapply:(A)Prior authorization determination.The Secretary shall make a determination, prior to the service beingfurnished, of whether the service would or would not meet the applicablerequirements of section 1862(a)(1)(A).(B)Denial of payment.Subject to paragraph(5), no payment may be made under this part for the service unlessthe Secretary determines pursuant to subparagraph (A) that the servicewould meet the applicable requirements of such section 1862(a)(1)(A).(4)Submissionof information.A chiropractor describedin section 1861(r)(5) may submitthe information necessary for medical review by fax, by mail, or byelectronic means. The Secretary shall make available the electronicmeans described in the preceding sentence as soon as practicable.(5)Timeliness.If the Secretary does not make a prior authorization determinationunder paragraph (3)(A) within 14 business days of the date of thereceipt of medical documentation needed to make such determination,paragraph (3)(B) shall not apply.(6)Applicationof limitation on beneficiary liability.Where payment may not be made as a result of the application of paragraph(2)(B), section 1879 shall applyin the same manner as such section applies to a denial that is madeby reason of section 1862(a)(1).(7)Reviewby contractors.The medical review describedin paragraph (2) may be conducted by medicare administrative contractorspursuant to section 1874A(a)(4)(G) or by any other contractor determined appropriate by the Secretarythat is not a recovery audit contractor.(8)Multipleservices.The Secretary shall, wherepracticable, apply the medical review under this subsection in a mannerso as to allow an individual described in paragraph (1) to obtain,at a single time rather than on a service-by-service basis, an authorizationin accordance with paragraph (3)(A) for multiple services.(9)Construction.With respect to a service described in paragraph (1) that hasbeen affirmed by medical review under this subsection, nothing inthis subsection shall be construed to preclude the subsequent denialof a claim for such service that does not meet other applicable requirementsunder this Act.(10)Authority.(A) The Secretary may implement theprovisions of this subsection by interim final rule with comment period.(B)Administration.Chapter 35 of title 44, United States Code, shall not applyto medical review under this subsection.(bb)[143]Additional Paymentsfor Certain Rural Health Clinics With Physicians or PractitionersReceiving DATA Waiveres.(1)In general.In the case of a rural health clinic with respect to which,beginning on or after January 1, 2019, rural health clinic services(as defined in section 1861(aa)(1)) are furnished for the treatment of opioid use disorder by a physicianor practitioner who meets the requirements described in paragraph(3), the Secretary shall, subject to availability of funds under paragraph(4), make a payment (at such time and in such manner as specifiedby the Secretary) to such rural health clinic after receiving andapproving an application described in paragraph (2). Such paymentshall be in an amount determined by the Secretary, based on an estimateof the average costs of training for purposes of receiving a waiverdescribed in paragraph (3)(B). Such payment may be made only one timewith respect to each such physician or practitioner.(2)ApplicationIn order to receive a payment described in paragraph (1), arural health clinic shall submit to the Secretary an application forsuch a payment at such time, in such manner, and containing such informationas specified by the Secretary. A rural health clinic may apply forsuch a payment for each physician or practitioner described in paragraph(1) furnishing services described in such paragraph at such clinic.(3)Requirements.For purposes of paragraph (1), the requirements described inthis paragraph, with respect to a physician or practitioner, are thefollowing:(A) The physician or practitioneris employed by or working under contract with a rural health clinicdescribed in paragraph (1) that submits an application under paragraph(2).(B) The physician or practitionerfirst receives a waiver under section 303(g)[144]of the Controlled SubstancesAct on or after January 1, 2019.(4)Funding.For purposes of making payments under this subsection, thereare appropriated, out of amounts in the Treasury not otherwise appropriated,$2,000,000, which shall remain available until expended.