evekhm/cms_iom_500 huggingface dataset:
Social Security Act §1833
(B)Form of payment.Payments under thissubsection shall be made in a lump sum, on an annual basis, as soonas practicable.(C)Treatment of payment incentive.Paymentsunder this subsection shall not be taken into account for purposesof determining actual expenditures under an alternative payment modeland for purposes of determining or rebasing any benchmarks used underthe alternative payment model.(D)Coordination.The amount of the additionalpayment under this subsection or subsection (m) shall be determinedwithout regard to any additional payment under subsection (m) andthis subsection, respectively. The amount of the additional paymentunder this subsection or subsection (x) shall be determined withoutregard to any additional payment under subsection (x) and this subsection,respectively. The amount of the additional payment under this subsectionor subsection (y) shall be determined without regard to any additionalpayment under subsection (y) and this subsection, respectively.(2)Qualifyingapm participant.For purposes of thissubsection, the term qualifying APM participant meansthe following:(A)2019 and 2020.With respect to 2019and 2020, an eligible professional for whom the Secretary determinesthat at least 25 percent of payments under this part for covered professionalservices furnished by such professional during the most recent periodfor which data are available (which may be less than a year) wereattributable to such services furnished under this part through aneligible alternative payment entity.(B)2021 and 2022.With respect to 2021and 2022, an eligible professional described in either of the followingclauses:(i)Medicarepayment threshold option.An eligibleprofessional for whom the Secretary determines that at least 50 percentof payments under this part for covered professional services furnishedby such professional during the most recent period for which dataare available (which may be less than a year) were attributable tosuch services furnished under this part through an eligible alternativepayment entity.(ii)Combinationall-payer and medicare payment threshold option.An eligible professional(I)for whomthe Secretary determines, with respect to items and services furnishedby such professional during the most recent period for which dataare available (which may be less than a year), that at least 50 percentof the sum of(aa)paymentsdescribed in clause (i); and
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(aa)paymentsdescribed in clause (i); and(bb)all otherpayments, regardless of payer (other than payments made by the Secretaryof Defense or the Secretary of Veterans Affairs and other than paymentsmade under title XIX in a State in which no medical home or alternativepayment model is available under the State program under that title),meet the requirement described in clause (iii)(I) with respect topayments described in item (aa) and meet the requirement describedin clause (iii)(II) with respect to payments described in item (bb);(II)for whomthe Secretary determines at least 25 percent of payments under thispart for covered professional services furnished by such professionalduring the most recent period for which data are available (whichmay be less than a year) were attributable to such services furnishedunder this part through an eligible alternative payment entity; and(III)whoprovides to the Secretary such information as is necessary for theSecretary to make a determination under subclause (I), with respectto such professional.(iii)Requirement.For purposes of clause(ii)(I)(I)the requirementdescribed in this subclause, with respect to payments described initem (aa) of such clause, is that such payments are made to an eligiblealternative payment entity; and(II)the requirementdescribed in this subclause, with respect to payments described initem (bb) of such clause, is that such payments are made under arrangementsin which(aa)qualitymeasures comparable to measures under the performance category describedin section 1848(q)(2)(B)(i) apply;(bb)certifiedEHR technology is used; and(cc)the eligibleprofessional participates in an entity that(AA)bearsmore than nominal financial risk if actual aggregate expendituresexceeds expected aggregate expenditures; or(BB)withrespect to beneficiaries under title XIX, is a medical home that meetscriteria comparable to medical homes expanded under section 1115A(c).(C)Beginning in 2023.With respect to2023 and each subsequent year, an eligible professional describedin either of the following clauses:(i)
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(C)Beginning in 2023.With respect to2023 and each subsequent year, an eligible professional describedin either of the following clauses:(i)Medicarepayment threshold option.An eligibleprofessional for whom the Secretary determines that at least 75 percentof payments under this part for covered professional services furnishedby such professional during the most recent period for which dataare available (which may be less than a year) were attributable tosuch services furnished under this part through an eligible alternativepayment entity.(ii)Combinationall-payer and medicare payment threshold option.An eligible professional(I)for whomthe Secretary determines, with respect to items and services furnishedby such professional during the most recent period for which dataare available (which may be less than a year), that at least 75 percentof the sum of(aa)paymentsdescribed in clause (i); and(bb)all otherpayments, regardless of payer (other than payments made by the Secretaryof Defense or the Secretary of Veterans Affairs and other than paymentsmade under title XIX in a State in which no medical home or alternativepayment model is available under the State program under that title),meet the requirement described in clause (iii)(I) with respect topayments described in item (aa) and meet the requirement describedin clause (iii)(II) with respect to payments described in item (bb);(II)for whomthe Secretary determines at least 25 percent of payments under thispart for covered professional services furnished by such professionalduring the most recent period for which data are available (whichmay be less than a year) were attributable to such services furnishedunder this part through an eligible alternative payment entity; and(III)whoprovides to the Secretary such information as is necessary for theSecretary to make a determination under subclause (I), with respectto such professional.(iii)Requirement.For purposes of clause(ii)(I)(I)the requirementdescribed in this subclause, with respect to payments described initem (aa) of such clause, is that such payments are made to an eligiblealternative payment entity; and(II)the requirementdescribed in this subclause, with respect to payments described initem (bb) of such clause, is that such payments are made under arrangementsin which
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(II)the requirementdescribed in this subclause, with respect to payments described initem (bb) of such clause, is that such payments are made under arrangementsin which(aa)qualitymeasures comparable to measures under the performance category describedin section 1848(q)(2)(B)(i) apply;(bb)certifiedEHR technology is used; and(cc)the eligibleprofessional participates in an entity that(AA)bearsmore than nominal financial risk if actual aggregate expendituresexceeds expected aggregate expenditures; or(BB)withrespect to beneficiaries under title XIX, is a medical home that meetscriteria comparable to medical homes expanded under section 1115A(c).(D)Use of patient approach.The Secretarymay base the determination of whether an eligible professional isa qualifying APM participant under this subsection and the determinationof whether an eligible professional is a partial qualifying APM participantunder section 1848(q)(1)(C)(iii) by using counts of patients in lieuof using payments and using the same or similar percentage criteria(as specified in this subsection and such section, respectively),as the Secretary determines appropriate.(3)Additionaldefinitions.In this subsection:(A)Covered professional services.Theterm covered professional services has the meaninggiven that term in section 1848(k)(3)(A).(B)Eligible professional.The term eligible professional has the meaning given that term insection 1848(k)(3)(B) and includes a group that includes such professionals.(C)Alternative payment model (apm).Theterm alternative payment model means, other than forpurposes of subparagraphs (B)(ii)(I)(bb) and (C)(ii)(I)(bb) of paragraph(2), any of the following:(i)A model undersection 1115A (other than a health care innovation award).(ii)The shared savingsprogram under section 1899.(iii)A demonstrationunder section 1866C.(iv)A demonstrationrequired by Federal law.(D)Eligible alternative payment entity.The term eligible alternative payment entity means,with respect to a year, an entity that(i)participates inan alternative payment model that
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(iv)A demonstrationrequired by Federal law.(D)Eligible alternative payment entity.The term eligible alternative payment entity means,with respect to a year, an entity that(i)participates inan alternative payment model that(I)requiresparticipants in such model to use certified EHR technology (as definedin subsection (o)(4)); and(II)providesfor payment for covered professional services based on quality measurescomparable to measures under the performance category described insection 1848(q)(2)(B)(i); and(ii)(I)bears financialrisk for monetary losses under such alternative payment model thatare in excess of a nominal amount; or(II)is a medicalhome expanded under section 1115A(c).(4)Limitation.There shall be no administrative or judicial review under section1869, 1878, or otherwise, of the following:(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)
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(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)
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(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.
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(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.
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[71]See Vol. II, P.L. 108-173,416, with respect to treatment of certain clinical diagnosticlaboratory tests furnished to hospital outpatients in certain ruralareas and 733, with respect to payments for pancreatic isletcell investigational transplants for medicare beneficiaries in clinicaltrials.See Vol. II, P.L. 112-96, 3005(d),with respect to the implementation of the amendments made by 3005;3005(e), with respect to the effective date for the amendmentto 1833(g)(5)(B); 3005(g), with respect to the collectionof additional data; and 3005(h), with respect to a GAO reporton manual medical review process implementation.[72]Formattingfor this subparagraph appears different than in law because of limitationsof the software used in designation of clauses and subclauses.[73]P.L. 113-93, 216(b)(1)(A)(i), struck (i) onthe basis and inserted (i)(I) on the basis. EffectiveApril 1, 2014.[74]P.L. 113-93, 216(b)(1)(A)(ii), struck subsection (h)(1)and inserted subsection (h)(1) (for tests furnished beforeJanuary 1, 2017). Effective April 1, 2014.[75]P.L.113-93, 216(b)(1)(A)(iii), struck or (ii) andinserted or (II) under section 1834A (for tests furnished onor after January 1, 2017), the amount paid shall be equal to 80 percent(or 100 percent, in the case of such tests for which payment is madeon an assignment-related basis) of the lesser of the amount determinedunder such section or the amount of the charges billed for the tests,or (ii). Effective April 1, 2014.P.L.113-93, 216(b)(1)(A)(iv), struck on the basisand inserted for tests furnished before January 1, 2017, onthe basis. Effective April 1, 2014.
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[76]As in original law. 2nd comma should be deleted.[77]P.L.114-113,504(b)(1) inserted subparagraph (AA). Effective for devicesfurnished on or after January 1, 2017.[78]P.L.114-255, 5012(c)(1), inserted new subparagraph (BB), Effectivefor items and services furnished on or after January 1, 2021.[79]P.L.115271, 2005(c), inserted subparagraph (CC). EffectiveOctober 24, 2018.[80]P.L. 113-93, 216(b)(1)(B)(i), struck (i) onthe basis and inserted (i)(I) on the basis. EffectiveApril 1, 2014.[81]P.L. 113-93, 216(b)(1)(B)(ii), struck subsection(h)(1) and inserted subsection (h)(1) (for tests furnishedbefore January 1, 2017). Effective April 1, 2014.[82]P.L.113-93, 216(b)(1)(B)(iii), struck or (ii) andinserted or (II) under section 1834A (for tests furnished onor after January 1, 2017), the amount paid shall be equal to 80 percent(or 100 percent, in the case of such tests for which payment is madeon an assignment-related basis or to a provider having an agreementunder section 1866) of the lesser of the amount determined under suchsection or the amount of the charges billed for the tests, or (ii).Effective April 1, 2014.[83]P.L. 113-93, 216(b)(1)(B)(iv), struck on the basisand inserted for tests furnished before January 1, 2017, onthe basis. Effective April 1, 2014.[84]As in original. Should be (o)rather than (O).[85]*Punctuation as in original.
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[86]P.L. 113-93, 216(b)(1)(C), struck on the basisand inserted for tests furnished before January 1, 2017, onthe basis. Effective April 1, 2014.[87]P.L. 112-96,3005(b)(1), struck out but not described in section 1833(a)(8)(B)and inserted but (except as provided in paragraph (6)) notdescribed in section 1833(a)(8)(B), effective February 22,2012.P.L. 115123, 50202(1) struckSubject to paragraphs (4) and (5); inserted (A)Subject to paragraphs (4) and (5) in paragraph (1); added thefollowing new sentence at the end of subparagraph (A), Thepreceding sentence shall not apply to expenses incurred with respectto services furnished after December 31, 2017.; and added newsubparagraph (B). Effective February 9, 2018.[88]P.L.112-96, 3005(b)(1), struck out but not described in section1833(a)(8)(B) and inserted but (except as provided inparagraph (6)) not described in section 1833(a)(8)(B),effective February 22, 2012.P.L. 115123,50202(2) struck Subject to paragraphs (4) and (5);inserted (A) Subject to paragraphs (4) and (5) in paragraph(3); added the following new sentence at the end of subparagraph (A),The preceding sentence shall not apply to expenses incurredwith respect to services furnished after December 31, 2017.;and added new subparagraph (B). Effective February 9, 2018.[89]P.L.112-96, 3005(a)(1), inserted (A).P.L. 11278, 304, struck December 31,2011 and inserted February 29, 2012. EffectiveDecember 23, 2011.
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P.L. 11278, 304, struck December 31,2011 and inserted February 29, 2012. EffectiveDecember 23, 2011.P.L. 112-96, 3005(a)(3), inserted and if therequirement of subparagraph (B) is met, effective February22, 2012.P.L. 112-96, 3005(a)(4), inserted made inaccordance with such requirement, effective February 22, 2012.P.L. 113-67 1103, struck out December 31,2013 and inserted March 31, 2014*, effectiveDecember 26, 2013.P.L. 113-93 103(1), struck out March 31, 2014and inserted March 31, 2015*, effective April 1, 2014.P.L. 114-10 202(a)(1), struck out March 31,2015 and inserted December 31, 2017, effectiveApril 16, 2015.[90]P.L.112-96, 3005(a)(5), added subparagraph (B), effective February22, 2012, applicable to services furnished on or after March 1, 2012.[91]P.L.112-96, 3005(a)(5), added subparagraph (C), effective February22, 2012.[92]P.L. 114-10 202(b)(1), Inserted , subjectto subparagraph (E),'' after manual medical review processthat, effective April 16, 2015.[93]P.L.112-240, 603(c), added subparagraph (D), effective January 2,2012.P.L. 115123, 50202(3)(A), redesignatedand moved this subparagraph 1833(g)(5)(D) to paragraph (g)(8). Theamendment did not redesignate subparagraph (E) below. Effective February9, 2018.