(19)Flooron area wage adjustment factor for hospital outpatient departmentservices in frontier states.(A)In general.Subject to subparagraph(B), with respect to covered OPD services furnished on or after January1, 2011, the area wage adjustment factor applicable under the paymentsystem established under this subsection to any hospital outpatientdepartment which is located in a frontier State (as defined in section 1886(d)(3)(E)(iii)(II)) maynot be less than 1.00. The preceding sentence shall not be appliedin a budget neutral manner.(B)Limitation.This paragraph shall notapply to any hospital outpatient department located in a State thatreceives a non-labor related share adjustment under section 1886(d)(5)(H).(20)Notbudget neutral application of reduced expenditures resulting fromquality incentives for computed tomography.The Secretary shall not take into account the reduced expendituresthat result from the application of section 1834(p) in making anybudget neutrality adjustments this subsection.[129](21)Servicesfurnished by an off-campus outpatient department of a provider[130].(A)Applicable items and services.Forpurposes of paragraph (1)(B)(v) and this paragraph, the term applicable items and services means items and services otherthan items and services furnished by a dedicated emergency department(as defined in section 489.24(b) of title 42 of the Code of FederalRegulations).(B)Off-campus outpatient department of a provider.(i)Ingeneral.[131]For purposes ofparagraph (1)(B)(v) and this paragraph, subject to the subsequentprovisions of this subparagraph, the term off- campus outpatientdepartment of a provider means a department of a provider(as defined in section 413.65(a)(2) of title 42 of the Code of FederalRegulations, as in effect as of the date of the enactment of thisparagraph) that is not located(I)on the campus(as defined in such section 413.65(a)(2)) of such provider; or(II)withinthe distance (described in such definition of campus) from a remotelocation of a hospital facility (as defined in such section 413.65(a)(2)).(ii)Exception.For purposes of paragraph (1)(B)(v) and this paragraph, theterm off-campus outpatient department of a provider shall not include a department of a provider (as so defined) thatwas billing under this subsection with respect to covered OPD servicesfurnished prior to the date of the enactment of this paragraph.(iii)Deemed treatment for 2017.For purposesof applying clause (ii) with respect to applicable items and servicesfurnished during 2017, a department of a provider (as so defined)not described in such clause is deemed to be billing under this subsectionwith respect to covered OPD services furnished prior to November 2,2015, if the Secretary received from the provider prior to December2, 2015, an attestation (pursuant to section 413.65(b)(3) of title42 of the Code of Federal Regulations) that such department was adepartment of a provider (as so defined).(iv)Alternativeexception beginning with 2018.For purposesof paragraph (1)(B)(v) and this paragraph with respect to applicableitems and services furnished during 2018 or a subsequent year, theterm off-campus outpatient department of a provider also shall not include a department of a provider (as so defined)that is not described in clause (ii) if(I) the Secretary receives from the provideran attestation (pursuant to such section 413.65(b)(3)) not later thanDecember 31, 2016 (or, if later, 60 days after the date of the enactmentof this clause), that such department met the requirements of a departmentof a provider specified in section 413.65 of title 42 of the Codeof Federal Regulations;(II) the provider includes such departmentas part of the provider on its enrollment form in accordance withthe enrollment process under section 1866(j); and(III) the department met the mid-buildrequirement of clause (v) and the Secretary receives, not later than60 days after the date of the enactment of this clause, from the chiefexecutive officer or chief operating officer of the provider a writtencertification that the department met such requirement.(v)Mid-buildrequirement described.The mid-buildrequirement of this clause is, with respect to a department of a provider,that before November 2, 2015, the provider had a binding written agreementwith an outside unrelated party for the actual construction of suchdepartment.(vi)Exclusion for certain cancerhospitals.[132]For purposes of paragraph(1)(B)(v) and this paragraph with respect to applicable items andservices furnished during 2017 or a subsequent year, the term off-campus outpatient department of a provider also shallnot include a department of a provider (as so defined) that is notdescribed in clause (ii) if the provider is a hospital described insection 1886(d)(1)(B)(v) and(I) in the case of a department thatmet the requirements of section 413.65 of title 42 of the Code ofFederal Regulations after November 1, 2015, and before the date ofthe enactment of this clause, the Secretary receives from the provideran attestation that such department met such requirements not laterthan 60 days after such date of enactment; or(II) in the case of a department thatmeets such requirements after such date of enactment, the Secretaryreceives from the provider an attestation that such department meetssuch requirements not later than 60 days after the date such requirementsare first met with respect to such department.(vii)Audit.[133]Not later than December 31, 2018, the Secretary shall auditthe compliance with requirements of clause (iv) with respect to eachdepartment of a provider to which such clause applies. Not later than2 years after the date the Secretary receives an attestation underclause (vi) relating to compliance of a department of a provider withrequirements referred to in such clause, the Secretary shall auditthe compliance with such requirements with respect to the department.and If the Secretary finds as a result of an audit under this clausethat the applicable requirements were not met with respect to suchdepartment, the department shall not be excluded from the term off- campus outpatient department of a provider under suchclause.(viii)Implementation.For purposes of implementingclauses (iii) through (vii):(I) Notwithstanding any other provisionof law, the Secretary may implement such clauses by program instructionor otherwise.(II) Subchapter I of chapter 35 of title44, United States Code, shall not apply.(III)[134]For purposes of carrying out this subparagraph with respectto clauses (iii) and (iv) (and clause (vii) insofar as it relatesto clause (iv)), $10,000,000 shall be available from the Federal SupplementaryMedical Insurance Trust Fund under section 1841, to remain availableuntil December 31, 2018. For purposes of carrying out this subparagraphwith respect to clause (vi) (and clause (vii) insofar as it relatesto such clause), $2,000,000 shall be available from the Federal SupplementaryMedical Insurance Trust Fund under section 1841, to remain availableuntil expended.(C)Availability of payment under other payment systems.Payments for applicable items and services furnished by an off-campusoutpatient department of a provider that are described in paragraph(1)(B)(v) shall be made under the applicable payment system underthis part (other than under this subsection) if the requirements forsuch payment are otherwise met.(D)Information needed for implementation.Each hospital shall provide to the Secretary such information asthe Secretary determines appropriate to implement this paragraph andparagraph (1)(B)(v) (which may include reporting of information ona hospital claim using a code or modifier and reporting informationabout off-campus outpatient departments of a provider on the enrollmentform described in section 1866(j)).(E)Limitations.There shall be no administrativeor judicial review under section 1869, section 1878, or otherwiseof the following:(i)The determinationof the applicable items and services under subparagraph (A) and applicablepayment systems under subparagraph (C).(ii)The determinationof whether a department of a provider meets the term described insubparagraph (B).(iii)Any informationthat hospitals are required to report pursuant to subparagraph (D).(iv)The determinationof an audit under subparagraph (B)(vii).[135]