evekhm/cms_iom_500 huggingface dataset:
Social Security Act §1862
In the subsection, the term primary plan meansa group health plan or large group health plan, to the extent thatclause (i) applies, and a workmens compensation law or plan,an automobile or liability insurance policy or plan (including a self-insuredplan) or no fault insurance, to the extent that clause (ii) applies.An entity that engages in a business, trade, or profession shall bedeemed to have a self-insured plan if it carries its own risk (whetherby a failure to obtain insurance, or otherwise) in whole or in part.(B)Conditional payment.(i)Authorityto make conditional payment.The Secretarymay make payment under this title with respect to an item or serviceif a primary plan described in subparagraph (A)(ii) has not made orcannot reasonably be expected to make payment with respect to suchitem or service promptly (as determined in accordance with regulations).Any such payment by the Secretary shall be conditioned on reimbursementto the appropriate Trust Fund in accordance with the succeeding provisionsof this subsection.(ii)Repaymentrequired.A primary plan[556], andan entity that receives payment from a primary plan, shall reimbursethe appropriate Trust Fund for any payment made by the Secretary underthis title with respect to an item or service if it is demonstratedthat such primary plan has or had a responsibility to make paymentwith respect to such item or service. A primary plans responsibilityfor such payment may be demonstrated by a judgment, a payment conditionedupon the recipients compromise, waiver, or release (whetheror not there is a determination or admission of liability) of paymentfor items or services included in a claim against the primary planor the primary plans insured, or by other means. If reimbursementis not made to the appropriate Trust Fund before the expiration ofthe 60-day period that begins on the date notice of, or informationrelated to, a primary plans responsibility for such paymentor other information is received, the Secretary may charge interest(beginning with the date on which the notice or other informationis received) on the amount of the reimbursement until reimbursementis made (at a rate determined by the Secretary in accordance withregulations of the Secretary of the Treasury applicable to chargesfor late payments).(iii)
Social Security Act §1862
(iii)Action by united states.In order torecover payment made under this title for an item or service, theUnited States may bring an action against any or all entities thatare or were required or responsible (directly, as an insurer or self-insurer,as a third-party administrator, as an employer that sponsors or contributesto a group health plan, or large group health plan, or otherwise)to make payment with respect to the same item or service (or any portionthereof) under a primary plan. The United States may, in accordancewith paragraph (3)(A) collect double damages against any such entity.In addition, the United States may recover under this clause fromany entity that has received payment from a primary plan or from theproceeds of a primary plans payment to any entity. The UnitedStates may not recover from a third-party administrator under thisclause in cases where the third-party administrator would not be ableto recover the amount at issue from the employer or group health planand is not employed by or under contract with the employer or grouphealth plan at the time the action for recovery is initiated by theUnited States or for whom it provides administrative services dueto the insolvency or bankruptcy of the employer or plan. An actionmay not be brought by the United States under this clause with respectto payment owed unless the complaint is filed not later than 3 yearsafter the date of the receipt of notice of a settlement, judgment,award, or other payment made pursuant to paragraph (8) relating tosuch payment owed.[557](iv)Subrogationrights.The United States shall be subrogated(to the extent of payment made under this title for such an item orservice) to any right under this subsection of an individual or anyother entity to payment with respect to such item or service undera primary plan.(v)Waiverof rights.The Secretary may waive (inwhole or in part) the provisions of this subparagraph in the caseof an individual claim if the Secretary determines that the waiveris in the best interests of the program established under this title.(vi)
Social Security Act §1862
(vi)Claims-filingperiod.Notwithstanding any other timelimits that may exist for filing a claim under an employer group healthplan, the United States may seek to recover conditional payments inaccordance with this subparagraph where the request for payment issubmitted to the entity required or responsible under this subsectionto pay with respect to the item or service (or any portion thereof)under a primary plan within the 3-year period beginning on the dateon which the item or service was furnished.(vii)[558]Use of websiteto determine final conditional reimbursement amount.(I)Notice to secretary of expected dateof a settlement, judgment, etc.In the case of a payment made by the Secretary pursuant to clause(i) for items and services provided to the claimant, the claimantor applicable plan (as defined in paragraph (8)(F)) may at any timebeginning 120 days before the reasonably expected date of a settlement,judgment, award, or other payment, notify the Secretary that a paymentis reasonably expected and the expected date of such payment.(II)Secretarial providing access to claims information through a website.The Secretary shall maintain and make available to individualsto whom items and services are furnished under this title (and toauthorized family or other representatives recognized under regulationsand to an applicable plan which has obtained the consent of the individual)access to information on the claims for such items and services (includingpayment amounts for such claims), including those claims that relateto a potential settlement, judgment, award, or other payment. Suchaccess shall be provided to an individual, representative, or planthrough a website that requires a password to gain access to the information.The Secretary shall update the information on claims and paymentson such website in as timely a manner as possible but not later than15 days after the date that payment is made. Information related toclaims and payments subject to the notice under subclause (I) shallbe maintained and made available consistent with the following:(aa)The informationshall be as complete as possible and shall include provider or suppliername, diagnosis codes (if any), dates of service, and conditionalpayment amounts.(bb)The informationaccurately identifies those claims and payments that are related toa potential settlement, judgment, award, or other payment to whichthe provisions of this subsection apply.
Social Security Act §1862
(bb)The informationaccurately identifies those claims and payments that are related toa potential settlement, judgment, award, or other payment to whichthe provisions of this subsection apply.(cc)The websiteprovides a method for the receipt of secure electronic communicationswith the individual, representative, or plan involved.(dd)The websiteprovides that information is transmitted from the website in a formthat includes an official time and date that the information is transmitted.(ee)The websiteshall permit the individual, representative, or plan to download astatement of reimbursement amounts (in this clause referred to asa statement of reimbursement amount) on payments forclaims under this title relating to a potential settlement, judgment,award, or other payment.(III)Use of timely web download as a basis for final conditionalamount.If an individual (or other claimantor applicable plan with the consent of the individual) obtains a statementof reimbursement amount from the website during the protected periodas defined in subclause (V) and the related settlement, judgment,award or other payment is made during such period, then the last statementof reimbursement amount that is downloaded during such period andwithin 3 business days before the date of the settlement, judgment,award, or other payment shall constitute the final conditional amountsubject to recovery under clause (ii) related to such settlement,judgment, award, or other payment.(IV)
Social Security Act §1862
(IV)Resolution of discrepancies.If theindividual (or authorized representative) believes there is a discrepancywith the statement of reimbursement amount, the Secretary shall providea timely process to resolve the discrepancy. Under such process theindividual (or representative) must provide documentation explainingthe discrepancy and a proposal to resolve such discrepancy. Within11 business days after the date of receipt of such documentation,the Secretary shall determine whether there is a reasonable basisto include or remove claims on the statement of reimbursement. Ifthe Secretary does not make such determination within the 11 business-dayperiod, then the proposal to resolve the discrepancy shall be accepted.If the Secretary determines within such period that there is not areasonable basis to include or remove claims on the statement of reimbursement,the proposal shall be rejected. If the Secretary determines withinsuch period that there is a reasonable basis to conclude there isa discrepancy, the Secretary must respond in a timely manner by agreeingto the proposal to resolve the discrepancy or by providing documentationshowing with good cause why the Secretary is not agreeing to suchproposal and establishing an alternate discrepancy resolution. Inno case shall the process under this subclause be treated as an appealsprocess or as establishing a right of appeal for a statement of reimbursementamount and there shall be no administrative or judicial review ofthe Secretarys determinations under this subclause.(V)
Social Security Act §1862
(V)Protected period.In subclause (III),the term protected period means, withrespect to a settlement, judgment, award or other payment relatingto an injury or incident, the portion (if any) of the period beginningon the date of notice under subclause (I) with respect to such settlement,judgment, award, or other payment that is after the end of a Secretarialresponse period beginning on the date of such notice to the Secretary.Such Secretarial response period shall be a period of 65 days, exceptthat such period may be extended by the Secretary for a period ofan additional 30 days if the Secretary determines that additionaltime is required to address claims for which payment has been made.Such Secretarial response period shall be extended and shall not includeany days for any part of which the Secretary determines (in accordancewith regulations) that there was a failure in the claims and paymentposting system and the failure was justified due to exceptional circumstances(as defined in such regulations). Such regulations shall define exceptionalcircumstances in a manner so that not more than 1 percent of the repaymentobligations under this subclause would qualify as exceptional circumstances(VI)Effective date.The Secretary shallpromulgate final regulations to carry out this clause not later than9 months after the date of the enactment of this clause.(VII)Website including successortechnology.In this clause, the term website includes any successor technology.(viii)[559]Right of appealfor secondary payer determinations relating to liability insurance(including self-insurance), no fault insurance, and workerscompensation laws and plans.The Secretaryshall promulgate regulations establishing a right of appeal and appealsprocess, with respect to any determination under this subsection fora payment made under this title for an item or service for which theSecretary is seeking to recover conditional payments from an applicableplan (as defined in paragraph (8)(F)) that is a primary plan undersubsection (A)(ii), under which the applicable plan involved, or anattorney, agent, or third party administrator on behalf of such plan,may appeal such determination. The individual furnished such an itemor service shall be notified of the plans intent to appealsuch determination[560](C)
Social Security Act §1862
(C)Treatment of questionnaires.The Secretarymay not fail to make payment under subparagraph (A) solely on theground that an individual failed to complete a questionnaire concerningthe existence of a primary plan.(3)Enforcement.(A)Private cause of action.There is establisheda private cause of action for damages (which shall be in an amountdouble the amount otherwise provided) in the case of a primary planwhich fails to provide for primary payment (or appropriate reimbursement)in accordance with paragraphs (1) and (2)(A).(B)Reference to excise tax with respect to nonconforming group healthplans.For provision imposing an excisetax with respect to nonconforming group health plans, see section5000 of the Internal Revenue Code of 1986[561].(C)Prohibition of financial incentives not to enroll in a group healthplan or a large group health plan.Itis unlawful for an employer or other entity to offer any financialor other incentive for an individual entitled to benefits under thistitle not to enroll (or to terminate enrollment) under a group healthplan or a large group health plan which would (in the case of suchenrollment) be a primary plan (as defined in paragraph (2)(A)). Anyentity that violates the previous sentence is subject to a civil moneypenalty of not to exceed $5,000 for each such violation. The provisionsof section 1128A  (other than subsections (a) and (b)) shall apply to a civil moneypenalty under the previous sentence in the same manner as such provisionsapply to a penalty or proceeding under section 1128A(a).(4)Coordinationof benefits.Where payment for an itemor service by a primary plan is less than the amount of the chargefor such item or service and is not payment in full, payment may bemade under this title (without regard to deductibles and coinsuranceunder this title) for the remainder of such charge, but(A)payment underthis title may not exceed an amount which would be payable under thistitle for such item or service if paragraph (2)(A) did not apply;and(B)payment underthis title, when combined with the amount payable under the primaryplan, may not exceed
Social Security Act §1862
(B)payment underthis title, when combined with the amount payable under the primaryplan, may not exceed(i)in the case ofan item or service payment for which is determined under this titleon the basis of reasonable cost (or other cost-related basis) or undersection 1886,the amount which would be payable under this title on such basis,and(ii)in the caseof an item or service for which payment is authorized under this titleon another basis(I)the amountwhich would be payable under the primary plan (without regard to deductiblesand coinsurance under such plan), or(II)the reasonablecharge or other amount which would be payable under this title (withoutregard to deductibles and coinsurance under this title),whichever is greater.(5)Identificationof secondary payer situations.(A)Requesting matching information.(i)Commissionerof social security.The Commissionerof Social Security shall, not less often that annually, transmit tothe Secretary of the Treasury a list of the names and TINs of Medicarebeneficiaries (as defined in section 6103(l)(12) of the Internal RevenueCode of 1986[562]) and request that the Secretary disclose to the Commissionerthe information described in subparagraph (A) of such section.(ii)Administrator.The Administrator of the Centers for Medicare and Medicaid Servicesshall request, not less often than annually, the Commissioner of theSocial Security Administration to disclose to the Administrator theinformation described in subparagraph (B) of section 6103(l)(12) ofthe Internal Revenue Code of 1986.(B)Disclosure to fiscal intermediaries and carriers.In addition to any other information provided under this titleto fiscal intermediaries and carriers, the Administrator shall discloseto such intermediaries and carriers (or to such a single intermediaryor carrier as the Secretary may designate) the information receivedunder subparagraph (A) for purposes of carrying out this subsection.(C)Contacting employers.(i)
Social Security Act §1862
(C)Contacting employers.(i)Ingeneral.With respect to each individual(in this subparagraph referred to as an employee) whowas furnished a written statement under section 6051 of the InternalRevenue Code of 1986[563]by a qualified employer (as definedin section 6103(l)(12)(E)(iii), of such Code[564]), asdisclosed under subparagraph (B)(i) the appropriate fiscal intermediaryor carrier shall contact the employer in order to determine duringwhat period the employee or employees spouse may be (or havebeen) covered under a group health plan of the employer and the natureof the coverage that is or was provided under the plan (includingthe name, address, and identifying number of the plan).(ii)Employerresponse.Within 30 days of the dateof receipt of the inquiry, the employer shall notify the intermediaryor carrier making the inquiry as to the determinations described inclause (i). An employer (other than a Federal or other governmentalentity) who willfully or repeatedly fails to provide timely and accuratenotice in accordance with the previous sentence shall be subject toa civil money penalty of not to exceed $1,000 for each individualwith respect to which such an inquiry is made. The provision of section 1128A (other than subsections(a) and (b)) shall apply to a civil money penalty under the previoussentence in the same manner as such provisions apply to a penaltyor proceeding under section 1128A(a).(D)Obtaining information from beneficiaries.Before an individual applies for benefits under part A or enrollsunder part B, the Administrator shall mail the individual a questionnaireto obtain information on whether the individual is covered under aprimary plan and the nature of the coverage provided under the plan,including the name, address, and identifying number of the plan.(E)Enddate.The provisions of this paragraphshall not apply to information required to be provided on or afterJuly 1, 2016.[565](6)Screeningrequirements for provider and suppliers.(A)
Social Security Act §1862
(E)Enddate.The provisions of this paragraphshall not apply to information required to be provided on or afterJuly 1, 2016.[565](6)Screeningrequirements for provider and suppliers.(A)In general.Notwithstanding any otherprovisions of this title, no payment may be made for any item or servicefurnished under part B unless the entity furnishing such item or servicecompletes (to the best of its knowledge and on the basis of informationobtained from the individual to whom the item or service is furnished)the portion of the claim form relating to the availability of otherhealth benefit plans.(B)Penalties.An entity that knowingly,willfully, and repeatedly fails to complete a claim form in accordancewith subparagraph (A) or provides inaccurate information relatingto the availability of other health benefit plans on a claim formunder such subparagraph shall be subject to a civil money penaltyof not to exceed $2,000 for each such incident. The provisions ofsection 1128A  (other than subsections (a) and (b)) shall apply to a civil moneypenalty under the previous sentence in the same manner as such provisionsapply to a penalty or proceeding under section 1128A(a).(7)Requiredsubmission of information by group health plans.(A)Requirement.On and after the firstday of the first calendar quarter beginning after the date that is1 year after the date of the enactment of this paragraph, an entityserving as an insurer or third party administrator for a group healthplan, as defined in paragraph (1)(A)(v), and, in the case of a grouphealth plan that is self-insured and self-administered, a plan administratoror fiduciary, shall(i)[566]secure from theplan sponsor and plan participants such information as the Secretaryshall specify for the purpose of identifying situations where thegroup health plan is or has been(I)a primaryplan to the program under this title; or(II)for calendarquarters beginning on or after January 1, 2020, a primary payer withrespect to benefits relating to prescription drug coverage under partD; and(ii)submit suchinformation to the Secretary in a form and manner (including frequency)specified by the Secretary.(B)Enforcement.(i)
Social Security Act §1862
(ii)submit suchinformation to the Secretary in a form and manner (including frequency)specified by the Secretary.(B)Enforcement.(i)Ingeneral.An entity, a plan administrator,or a fiduciary described in subparagraph (A) that fails to complywith the requirements under such subparagraph shall be subject toa civil money penalty of $1,000 for each day of noncompliance foreach individual for which the information under such subparagraphshould have been submitted. The provisions of subsections (e) and(k) of section 1128A shall apply to a civil money penalty under the previous sentencein the same manner as such provisions apply to a penalty or proceedingunder section 1128A(a). A civil money penalty under this clause shall be in addition toany other penalties prescribed by law and in addition to any Medicaresecondary payer claim under this title with respect to an individual.(ii)Depositof amounts collected.Any amounts collectedpursuant to clause (i) shall be deposited in the Federal HospitalInsurance Trust Fund under section 1817.(C)Sharing of information.Notwithstandingany other provision of law, under terms and conditions establishedby the Secretary, the Secretary(i)shall share informationon entitlement under Part A and enrollment under Part B under thistitle with entities, plan administrators, and fiduciaries describedin subparagraph (A);(ii)may share theentitlement and enrollment information described in clause (i) withentities and persons not described in such clause; and(iii)may shareinformation collected under this paragraph as necessary for purposesof the proper coordination of benefits.(D)Implementation.Notwithstanding anyother provision of law, the Secretary may implement this paragraphby program instruction or otherwise.(8)Requiredsubmission of information by or on behalf of liability insurance (includingself-insurance), no fault insurance, and workers compensationlaws and plans.(A)Requirement.On and after the firstday of the first calendar quarter beginning after the date that is18 months after the date of the enactment of this paragraph, an applicableplan shall(i)determine whethera claimant (including an individual whose claim is unresolved) isentitled to benefits under the program under this title on any basis;and