42 U.S.C. § 1395cc : US Code - Section 1395CC: Agreements with providers of services; enrollment processes

Search 42 U.S.C. § 1395cc : US Code - Section 1395CC: Agreements with providers of services; enrollment processes

(a) Filing of agreements; eligibility for payment; charges with
respect to items and services
(1) Any provider of services (except a fund designated for
purposes of section 1395f(g) and section 1395n(e) of this title)
shall be qualified to participate under this subchapter and shall
be eligible for payments under this subchapter if it files with the
Secretary an agreement -
(A)(i) not to charge, except as provided in paragraph (2), any
individual or any other person for items or services for which
such individual is entitled to have payment made under this
subchapter (or for which he would be so entitled if such provider
of services had complied with the procedural and other
requirements under or pursuant to this subchapter or for which
such provider is paid pursuant to the provisions of section
1395f(e) of this title), and (ii) not to impose any charge that
is prohibited under section 1396a(n)(3) of this title,
(B) not to charge any individual or any other person for items
or services for which such individual is not entitled to have
payment made under this subchapter because payment for expenses
incurred for such items or services may not be made by reason of
the provisions of paragraph (1) or (9) of section 1395y(a) of
this title, but only if (i) such individual was without fault in
incurring such expenses and (ii) the Secretary's determination
that such payment may not be made for such items and services was
made after the third year following the year in which notice of
such payment was sent to such individual; except that the
Secretary may reduce such three-year period to not less than one
year if he finds such reduction is consistent with the objectives
of this subchapter,
(C) to make adequate provision for return (or other
disposition, in accordance with regulations) of any moneys
incorrectly collected from such individual or other person,
(D) to promptly notify the Secretary of its employment of an
individual who, at any time during the year preceding such
employment, was employed in a managerial, accounting, auditing,
or similar capacity (as determined by the Secretary by
regulation) by an agency or organization which serves as a fiscal
intermediary or carrier (for purposes of part A or part B, or
both, of this subchapter) with respect to the provider,
(E) to release data with respect to patients of such provider
upon request to an organization having a contract with the
Secretary under part B of subchapter XI of this chapter as may be
necessary (i) to allow such organization to carry out its
functions under such contract, or (ii) to allow such organization
to carry out similar review functions under any contract the
organization may have with a private or public agency paying for
health care in the same area with respect to patients who
authorize release of such data for such purposes,
(F)(i) in the case of hospitals which provide inpatient
hospital services for which payment may be made under subsection
(b), (c), or (d) of section 1395ww of this title, to maintain an
agreement with a professional standards review organization (if
there is such an organization in existence in the area in which
the hospital is located) or with a utilization and quality
control peer review organization which has a contract with the
Secretary under part B of subchapter XI of this chapter for the
area in which the hospital is located, under which the
organization will perform functions under that part with respect
to the review of the validity of diagnostic information provided
by such hospital, the completeness, adequacy, and quality of care
provided, the appropriateness of admissions and discharges, and
the appropriateness of care provided for which additional
payments are sought under section 1395ww(d)(5) of this title,
with respect to inpatient hospital services for which payment may
be made under part A of this subchapter (and for purposes of
payment under this subchapter, the cost of such agreement to the
hospital shall be considered a cost incurred by such hospital in
providing inpatient services under part A of this subchapter, and
(I) shall be paid directly by the Secretary to such organization
on behalf of such hospital in accordance with a rate per review
established by the Secretary, (II) shall be transferred from the
Federal Hospital Insurance Trust Fund, without regard to amounts
appropriated in advance in appropriation Acts, in the same manner
as transfers are made for payment for services provided directly
to beneficiaries, and (III) shall not be less in the aggregate
for a fiscal year than the aggregate amount expended in fiscal
year 1988 for direct and administrative costs (adjusted for
inflation and for any direct or administrative costs incurred as
a result of review functions added with respect to a subsequent
fiscal year) of such reviews),
(ii) in the case of hospitals, critical access hospitals,
skilled nursing facilities, and home health agencies, to maintain
an agreement with a utilization and quality control peer review
organization (which has a contract with the Secretary under part
B of subchapter XI of this chapter for the area in which the
hospital, facility, or agency is located) to perform the
functions described in paragraph (3)(A),
(G) in the case of hospitals which provide inpatient hospital
services for which payment may be made under subsection (b) or
(d) of section 1395ww of this title, not to charge any individual
or any other person for inpatient hospital services for which
such individual would be entitled to have payment made under part
A of this subchapter but for a denial or reduction of payments
under section 1395ww(f)(2) of this title,
(H)(i) in the case of hospitals which provide services for
which payment may be made under this subchapter and in the case
of critical access hospitals which provide critical access
hospital services, to have all items and services (other than
physicians' services as defined in regulations for purposes of
section 1395y(a)(14) of this title, and other than services
described by section 1395x(s)(2)(K) of this title, certified
nurse-midwife services, qualified psychologist services, and
services of a certified registered nurse anesthetist) (I) that
are furnished to an individual who is a patient of the hospital,
and (II) for which the individual is entitled to have payment
made under this subchapter, furnished by the hospital or
otherwise under arrangements (as defined in section 1395x(w)(1)
of this title) made by the hospital,
(ii) in the case of skilled nursing facilities which provide
covered skilled nursing facility services -
(I) that are furnished to an individual who is a resident of
the skilled nursing facility during a period in which the
resident is provided covered post-hospital extended care
services (or, for services described in section 1395x(s)(2)(D)
of this title, that are furnished to such an individual without
regard to such period), and
(II) for which the individual is entitled to have payment
made under this subchapter,
to have items and services (other than services described in
section 1395yy(e)(2)(A)(ii) of this title) furnished by the
skilled nursing facility or otherwise under arrangements (as
defined in section 1395x(w)(1) of this title) made by the skilled
nursing facility,
(I) in the case of a hospital or critical access hospital -
(i) to adopt and enforce a policy to ensure compliance with
the requirements of section 1395dd of this title and to meet
the requirements of such section,
(ii) to maintain medical and other records related to
individuals transferred to or from the hospital for a period of
five years from the date of the transfer, and
(iii) to maintain a list of physicians who are on call for
duty after the initial examination to provide treatment
necessary to stabilize an individual with an emergency medical
condition,
(J) in the case of hospitals which provide inpatient hospital
services for which payment may be made under this subchapter, to
be a participating provider of medical care under any health plan
contracted for under section 1079 or 1086 of title 10, or under
section 1713 (!1) of title 38, in accordance with admission
practices, payment methodology, and amounts as prescribed under
joint regulations issued by the Secretary and by the Secretaries
of Defense and Transportation, in implementation of sections 1079
and 1086 of title 10,
(K) not to charge any individual or any other person for items
or services for which payment under this subchapter is denied
under section 1320c-3(a)(2) of this title by reason of a
determination under section 1320c-3(a)(1)(B) of this title,
(L) in the case of hospitals which provide inpatient hospital
services for which payment may be made under this subchapter, to
be a participating provider of medical care under section 1703 of
title 38, in accordance with such admission practices, and such
payment methodology and amounts, as are prescribed under joint
regulations issued by the Secretary and by the Secretary of
Veterans Affairs in implementation of such section,
(M) in the case of hospitals, to provide to each individual who
is entitled to benefits under part A of this subchapter (or to a
person acting on the individual's behalf), at or about the time
of the individual's admission as an inpatient to the hospital, a
written statement (containing such language as the Secretary
prescribes consistent with this paragraph) which explains -
(i) the individual's rights to benefits for inpatient
hospital services and for post-hospital services under this
subchapter,
(ii) the circumstances under which such an individual will
and will not be liable for charges for continued stay in the
hospital,
(iii) the individual's right to appeal denials of benefits
for continued inpatient hospital services, including the
practical steps to initiate such an appeal, and
(iv) the individual's liability for payment for services if
such a denial of benefits is upheld on appeal,
and which provides such additional information as the Secretary
may specify,
(N) in the case of hospitals and critical access hospitals -
(i) to make available to its patients the directory or
directories of participating physicians (published under
section 1395u(h)(4) of this title) for the area served by the
hospital or critical access hospital,
(ii) if hospital personnel (including staff of any emergency
or outpatient department) refer a patient to a nonparticipating
physician for further medical care on an outpatient basis, the
personnel must inform the patient that the physician is a
nonparticipating physician and, whenever practicable, must
identify at least one qualified participating physician who is
listed in such a directory and from whom the patient may
receive the necessary services,
(iii) to post conspicuously in any emergency department a
sign (in a form specified by the Secretary) specifying rights
of individuals under section 1395dd of this title with respect
to examination and treatment for emergency medical conditions
and women in labor, and
(iv) to post conspicuously (in a form specified by the
Secretary) information indicating whether or not the hospital
participates in the medicaid program under a State plan
approved under subchapter XIX of this chapter,
(O) to accept as payment in full for services that are covered
under this subchapter and are furnished to any individual
enrolled with a Medicare+Choice organization under part C of this
subchapter, with a PACE provider under section 1395eee or 1396u-4
of this title, or with an eligible organization with a risk-
sharing contract under section 1395mm of this title, under
section 1395mm(i)(2)(A) of this title (as in effect before
February 1, 1985), under section 1395b-1(a) of this title, or
under section 222(a) of the Social Security Amendments of 1972,
which does not have a contract (or, in the case of a PACE
provider, contract or other agreement) establishing payment
amounts for services furnished to members of the organization or
PACE program eligible individuals enrolled with the PACE
provider, the amounts that would be made as a payment in full
under this subchapter (less any payments under sections
1395ww(d)(11) and 1395ww(h)(3)(D) of this title) if the
individuals were not so enrolled,
(P) in the case of home health agencies which provide home
health services to individuals entitled to benefits under this
subchapter who require catheters, catheter supplies, ostomy bags,
and supplies related to ostomy care (described in section
1395x(m)(5) of this title), to offer to furnish such supplies to
such an individual as part of their furnishing of home health
services,
(Q) in the case of hospitals, skilled nursing facilities, home
health agencies, and hospice programs, to comply with the
requirement of subsection (f) of this section (relating to
maintaining written policies and procedures respecting advance
directives),
(R) to contract only with a health care clearinghouse (as
defined in section 1320d of this title) that meets each standard
and implementation specification adopted or established under
part C of subchapter XI of this chapter on or after the date on
which the health care clearinghouse is required to comply with
the standard or specification,
(S) in the case of a hospital that has a financial interest (as
specified by the Secretary in regulations) in an entity to which
individuals are referred as described in section
1395x(ee)(2)(H)(ii) of this title, or in which such an entity has
such a financial interest, or in which another entity has such a
financial interest (directly or indirectly) with such hospital
and such an entity, to maintain and disclose to the Secretary (in
a form and manner specified by the Secretary) information on -
(i) the nature of such financial interest,
(ii) the number of individuals who were discharged from the
hospital and who were identified as requiring home health
services, and
(iii) the percentage of such individuals who received such
services from such provider (or another such provider),
(T) in the case of hospitals and critical access hospitals, to
furnish to the Secretary such data as the Secretary determines
appropriate pursuant to subparagraph (E) of section 1395ww(d)(12)
of this title to carry out such section,
(U) in the case of hospitals which furnish inpatient hospital
services for which payment may be made under this subchapter, to
be a participating provider of medical care both -
(i) under the contract health services program funded by the
Indian Health Service and operated by the Indian Health
Service, an Indian tribe, or tribal organization (as those
terms are defined in section 1603 of title 25), with respect to
items and services that are covered under such program and
furnished to an individual eligible for such items and services
under such program; and
(ii) under any program funded by the Indian Health Service
and operated by an urban Indian organization with respect to
the purchase of items and services for an eligible urban Indian
(as those terms are defined in such section 1603),
in accordance with regulations promulgated by the Secretary
regarding admission practices, payment methodology, and rates of
payment (including the acceptance of no more than such payment
rate as payment in full for such items and services,(!2) and
(V) in the case of hospitals that are not otherwise subject to
the Occupational Safety and Health Act of 1970 [29 U.S.C. 651 et
seq.] (or a State occupational safety and health plan that is
approved under 18(b) (!3) of such Act [29 U.S.C. 667(b)]), to
comply with the Bloodborne Pathogens standard under section
1910.1030 of title 29 of the Code of Federal Regulations (or as
subsequently redesignated).
In the case of a hospital which has an agreement in effect with an
organization described in subparagraph (F), which organization's
contract with the Secretary under part B of subchapter XI of this
chapter is terminated on or after October 1, 1984, the hospital
shall not be determined to be out of compliance with the
requirement of such subparagraph during the six month period
beginning on the date of the termination of that contract.
(2)(A) A provider of services may charge such individual or other
person (i) the amount of any deduction or coinsurance amount
imposed pursuant to section 1395e(a)(1), (a)(3), or (a)(4), section
1395l(b), or section 1395x(y)(3) of this title with respect to such
items and services (not in excess of the amount customarily charged
for such items and services by such provider), and (ii) an amount
equal to 20 per centum of the reasonable charges for such items and
services (not in excess of 20 per centum of the amount customarily
charged for such items and services by such provider) for which
payment is made under part B of this subchapter or which are
durable medical equipment furnished as home health services (but in
the case of items and services furnished to individuals with end-
stage renal disease, an amount equal to 20 percent of the
estimated amounts for such items and services calculated on the
basis established by the Secretary). In the case of items and
services described in section 1395l(c) of this title, clause (ii)
of the preceding sentence shall be applied by substituting for 20
percent the proportion which is appropriate under such section. A
provider of services may not impose a charge under clause (ii) of
the first sentence of this subparagraph with respect to items and
services described in section 1395x(s)(10)(A) of this title and
with respect to clinical diagnostic laboratory tests for which
payment is made under part B of this subchapter. Notwithstanding
the first sentence of this subparagraph, a home health agency may
charge such an individual or person, with respect to covered items
subject to payment under section 1395m(a) of this title, the amount
of any deduction imposed under section 1395l(b) of this title and
20 percent of the payment basis described in section 1395m(a)(1)(B)
of this title. In the case of items and services for which payment
is made under part B of this subchapter under the prospective
payment system established under section 1395l(t) of this title,
clause (ii) of the first sentence shall be applied by substituting
for 20 percent of the reasonable charge, the applicable copayment
amount established under section 1395l(t)(5) (!1) of this title. In
the case of services described in section 1395l(a)(8) of this title
or section 1395l(a)(9) of this title for which payment is made
under part B of this subchapter under section 1395m(k) of this
title, clause (ii) of the first sentence shall be applied by
substituting for 20 percent of the reasonable charge for such
services 20 percent of the lesser of the actual charge or the
applicable fee schedule amount (as defined in such section) for
such services.
(B) Where a provider of services has furnished, at the request of
such individual, items or services which are in excess of or more
expensive than the items or services with respect to which payment
may be made under this subchapter, such provider of services may
also charge such individual or other person for such more expensive
items or services to the extent that the amount customarily charged
by it for the items or services furnished at such request exceeds
the amount customarily charged by it for the items or services with
respect to which payment may be made under this subchapter.
(C) A provider of services may in accordance with its customary
practice also appropriately charge any such individual for any
whole blood (or equivalent quantities of packed red blood cells, as
defined under regulations) furnished him with respect to which a
deductible is imposed under section 1395e(a)(2) of this title,
except that (i) any excess of such charge over the cost to such
provider for the blood (or equivalent quantities of packed red
blood cells, as so defined) shall be deducted from any payment to
such provider under this subchapter, (ii) no such charge may be
imposed for the cost of administration of such blood (or equivalent
quantities of packed red blood cells, as so defined), and (iii)
such charge may not be made to the extent such blood (or equivalent
quantities of packed red blood cells, as so defined) has been
replaced on behalf of such individual or arrangements have been
made for its replacement on his behalf. For purposes of this
subparagraph, whole blood (or equivalent quantities of packed red
blood cells, as so defined) furnished an individual shall be deemed
replaced when the provider of services is given one pint of blood
for each pint of blood (or equivalent quantities of packed red
blood cells, as so defined) furnished such individual with respect
to which a deduction is imposed under section 1395e(a)(2) of this
title.
(D) Where a provider of services customarily furnishes items or
services which are in excess of or more expensive than the items or
services with respect to which payment may be made under this
subchapter, such provider, notwithstanding the preceding provisions
of this paragraph, may not, under the authority of subparagraph
(B)(ii) of this paragraph, charge any individual or other person
any amount for such items or services in excess of the amount of
the payment which may otherwise be made for such items or services
under this subchapter if the admitting physician has a direct or
indirect financial interest in such provider.
(3)(A) Under the agreement required under paragraph (1)(F)(ii),
the peer review organization must perform functions (other than
those covered under an agreement under paragraph (1)(F)(i)) under
the third sentence of section 1320c-3(a)(4)(A) of this title and
under section 1320c-3(a)(14) of this title with respect to
services, furnished by the hospital, critical access hospital,
facility, or agency involved, for which payment may be made under
this subchapter.
(B) For purposes of payment under this subchapter, the cost of
such an agreement to the hospital, critical access hospital,
facility, or agency shall be considered a cost incurred by such
hospital, critical access hospital, facility, or agency in
providing covered services under this subchapter and shall be paid
directly by the Secretary to the peer review organization on behalf
of such hospital, critical access hospital, facility, or agency in
accordance with a schedule established by the Secretary.
(C) Such payments -
(i) shall be transferred in appropriate proportions from the
Federal Hospital Insurance Trust Fund and from the Federal
Supplementary Medical Insurance Trust Fund, without regard to
amounts appropriated in advance in appropriation Acts, in the
same manner as transfers are made for payment for services
provided directly to beneficiaries, and
(ii) shall not be less in the aggregate for a fiscal year -
(I) in the case of hospitals, than the amount specified in
paragraph (1)(F)(i)(III), and
(II) in the case of facilities, critical access hospitals,
and agencies, than the amounts the Secretary determines to be
sufficient to cover the costs of such organizations' conducting
the activities described in subparagraph (A) with respect to
such facilities, critical access hospitals, or agencies under
part B of subchapter XI of this chapter.
(b) Termination or nonrenewal of agreements
(1) A provider of services may terminate an agreement with the
Secretary under this section at such time and upon such notice to
the Secretary and the public as may be provided in regulations,
except that notice of more than six months shall not be required.
(2) The Secretary may refuse to enter into an agreement under
this section or, upon such reasonable notice to the provider and
the public as may be specified in regulations, may refuse to renew
or may terminate such an agreement after the Secretary -
(A) has determined that the provider fails to comply
substantially with the provisions of the agreement, with the
provisions of this subchapter and regulations thereunder, or with
a corrective action required under section 1395ww(f)(2)(B) of
this title,
(B) has determined that the provider fails substantially to
meet the applicable provisions of section 1395x of this title,
(C) has excluded the provider from participation in a program
under this subchapter pursuant to section 1320a-7 of this title
or section 1320a-7a of this title, or
(D) has ascertained that the provider has been convicted of a
felony under Federal or State law for an offense which the
Secretary determines is detrimental to the best interests of the
program or program beneficiaries.
(3) A termination of an agreement or a refusal to renew an
agreement under this subsection shall become effective on the same
date and in the same manner as an exclusion from participation
under the programs under this subchapter becomes effective under
section 1320a-7(c) of this title.
(4)(A) A hospital that fails to comply with the requirement of
subsection (a)(1)(V) of this section (relating to the Bloodborne
Pathogens standard) is subject to a civil money penalty in an
amount described in subparagraph (B), but is not subject to
termination of an agreement under this section.
(B) The amount referred to in subparagraph (A) is an amount that
is similar to the amount of civil penalties that may be imposed
under section 17 of the Occupational Safety and Health Act of 1970
[29 U.S.C. 666] for a violation of the Bloodborne Pathogens
standard referred to in subsection (a)(1)(U) (!4) of this section
by a hospital that is subject to the provisions of such Act [29
U.S.C. 651 et seq.].
(C) A civil money penalty under this paragraph shall be imposed
and collected in the same manner as civil money penalties under
subsection (a) of section 1320a-7a of this title are imposed and
collected under that section.
(c) Refiling after termination or nonrenewal; agreements with
skilled nursing facilities
(1) Where the Secretary has terminated or has refused to renew an
agreement under this subchapter with a provider of services, such
provider may not file another agreement under this subchapter
unless the Secretary finds that the reason for the termination or
nonrenewal has been removed and that there is reasonable assurance
that it will not recur.
(2) Where the Secretary has terminated or has refused to renew an
agreement under this subchapter with a provider of services, the
Secretary shall promptly notify each State agency which administers
or supervises the administration of a State plan approved under
subchapter XIX of this chapter of such termination or nonrenewal.
(d) Decision to withhold payment for failure to review long-stay
cases
If the Secretary finds that there is a substantial failure to
make timely review in accordance with section 1395x(k) of this
title of long-stay cases in a hospital, he may, in lieu of
terminating his agreement with such hospital, decide that, with
respect to any individual admitted to such hospital after a
subsequent date specified by him, no payment shall be made under
this subchapter for inpatient hospital services (including
inpatient psychiatric hospital services) after the 20th day of a
continuous period of such services. Such decision may be made
effective only after such notice to the hospital and to the public,
as may be prescribed by regulations, and its effectiveness shall
terminate when the Secretary finds that the reason therefor has
been removed and that there is reasonable assurance that it will
not recur. The Secretary shall not make any such decision except
after reasonable notice and opportunity for hearing to the
institution or agency affected thereby.
(e) "Provider of services" defined
For purposes of this section, the term "provider of services"
shall include -
(1) a clinic, rehabilitation agency, or public health agency
if, in the case of a clinic or rehabilitation agency, such clinic
or agency meets the requirements of section 1395x(p)(4)(A) of
this title (or meets the requirements of such section through the
operation of section 1395x(g) of this title), or if, in the case
of a public health agency, such agency meets the requirements of
section 1395x(p)(4)(B) of this title (or meets the requirements
of such section through the operation of section 1395x(g) of this
title), but only with respect to the furnishing of outpatient
physical therapy services (as therein defined) or (through the
operation of section 1395x(g) of this title) with respect to the
furnishing of outpatient occupational therapy services; and
(2) a community mental health center (as defined in section
1395x(ff)(3)(B) of this title), but only with respect to the
furnishing of partial hospitalization services (as described in
section 1395x(ff)(1) of this title).
(f) Maintenance of written policies and procedures
(1) For purposes of subsection (a)(1)(Q) of this section and
sections 1395i-3(c)(2)(E), 1395l(s), 1395w-25(i), 1395mm(c)(8), and
1395bbb(a)(6) of this title, the requirement of this subsection is
that a provider of services, Medicare+Choice organization, or
prepaid or eligible organization (as the case may be) maintain
written policies and procedures with respect to all adult
individuals receiving medical care by or through the provider or
organization -
(A) to provide written information to each such individual
concerning -
(i) an individual's rights under State law (whether statutory
or as recognized by the courts of the State) to make decisions
concerning such medical care, including the right to accept or
refuse medical or surgical treatment and the right to formulate
advance directives (as defined in paragraph (3)), and
(ii) the written policies of the provider or organization
respecting the implementation of such rights;
(B) to document in a prominent part of the individual's current
medical record whether or not the individual has executed an
advance directive;
(C) not to condition the provision of care or otherwise
discriminate against an individual based on whether or not the
individual has executed an advance directive;
(D) to ensure compliance with requirements of State law
(whether statutory or as recognized by the courts of the State)
respecting advance directives at facilities of the provider or
organization; and
(E) to provide (individually or with others) for education for
staff and the community on issues concerning advance directives.
Subparagraph (C) shall not be construed as requiring the provision
of care which conflicts with an advance directive.
(2) The written information described in paragraph (1)(A) shall
be provided to an adult individual -
(A) in the case of a hospital, at the time of the individual's
admission as an inpatient,
(B) in the case of a skilled nursing facility, at the time of
the individual's admission as a resident,
(C) in the case of a home health agency, in advance of the
individual coming under the care of the agency,
(D) in the case of a hospice program, at the time of initial
receipt of hospice care by the individual from the program, and
(E) in the case of an eligible organization (as defined in
section 1395mm(b) of this title) or an organization provided
payments under section 1395l(a)(1)(A) of this title or a
Medicare+Choice organization, at the time of enrollment of the
individual with the organization.
(3) In this subsection, the term "advance directive" means a
written instruction, such as a living will or durable power of
attorney for health care, recognized under State law (whether
statutory or as recognized by the courts of the State) and relating
to the provision of such care when the individual is incapacitated.
(4) For construction relating to this subsection, see section
14406 of this title (relating to clarification respecting assisted
suicide, euthanasia, and mercy killing).
(g) Penalties for improper billing
Except as permitted under subsection (a)(2) of this section, any
person who knowingly and willfully presents, or causes to be
presented, a bill or request for payment inconsistent with an
arrangement under subsection (a)(1)(H) of this section or in
violation of the requirement for such an arrangement, is subject to
a civil money penalty of not to exceed $2,000. The provisions of
section 1320a-7a of this title (other than subsections (a) and (b))
shall apply to a civil money penalty under the previous sentence in
the same manner as such provisions apply to a penalty or proceeding
under section 1320a-7a(a) of this title.
(h) Dissatisfaction with determination of Secretary; appeal by
institutions or agencies; single notice and hearing
(1)(A) Except as provided in paragraph (2), an institution or
agency dissatisfied with a determination by the Secretary that it
is not a provider of services or with a determination described in
subsection (b)(2) of this section shall be entitled to a hearing
thereon by the Secretary (after reasonable notice) to the same
extent as is provided in section 405(b) of this title, and to
judicial review of the Secretary's final decision after such
hearing as is provided in section 405(g) of this title, except
that, in so applying such sections and in applying section 405(l)
of this title thereto, any reference therein to the Commissioner of
Social Security or the Social Security Administration shall be
considered a reference to the Secretary or the Department of Health
and Human Services, respectively.
(B) An institution or agency described in subparagraph (A) that
has filed for a hearing under subparagraph (A) shall have expedited
access to judicial review under this subparagraph in the same
manner as providers of services, suppliers, and individuals
entitled to benefits under part A of this subchapter or enrolled
under part B of this subchapter, or both, may obtain expedited
access to judicial review under the process established under
section 1395ff(b)(2) of this title. Nothing in this subparagraph
shall be construed to affect the application of any remedy imposed
under section 1395i-3 of this title during the pendency of an
appeal under this subparagraph.
(C)(i) The Secretary shall develop and implement a process to
expedite proceedings under this subsection in which -
(I) the remedy of termination of participation has been
imposed;
(II) a remedy described in clause (i) or (iii) of section 1395i-
3(h)(2)(B) of this title has been imposed, but only if such
remedy has been imposed on an immediate basis; or
(III) a determination has been made as to a finding of
substandard quality of care that results in the loss of approval
of a skilled nursing facility's nurse aide training program.
(ii) Under such process under clause (i), priority shall be
provided in cases of termination described in clause (i)(I).
(iii) Nothing in this subparagraph shall be construed to affect
the application of any remedy imposed under section 1395i-3 of this
title during the pendency of an appeal under this subparagraph.
(2) An institution or agency is not entitled to separate notice
and opportunity for a hearing under both section 1320a-7 of this
title and this section with respect to a determination or
determinations based on the same underlying facts and issues.
(i) Intermediate sanctions for psychiatric hospitals
(1) If the Secretary determines that a psychiatric hospital which
has an agreement in effect under this section no longer meets the
requirements for a psychiatric hospital under this subchapter and
further finds that the hospital's deficiencies -
(A) immediately jeopardize the health and safety of its
patients, the Secretary shall terminate such agreement; or
(B) do not immediately jeopardize the health and safety of its
patients, the Secretary may terminate such agreement, or provide
that no payment will be made under this subchapter with respect
to any individual admitted to such hospital after the effective
date of the finding, or both.
(2) If a psychiatric hospital, found to have deficiencies
described in paragraph (1)(B), has not complied with the
requirements of this subchapter -
(A) within 3 months after the date the hospital is found to be
out of compliance with such requirements, the Secretary shall
provide that no payment will be made under this subchapter with
respect to any individual admitted to such hospital after the end
of such 3-month period, or
(B) within 6 months after the date the hospital is found to be
out of compliance with such requirements, no payment may be made
under this subchapter with respect to any individual in the
hospital until the Secretary finds that the hospital is in
compliance with the requirements of this subchapter.
(j) Enrollment process for providers of services and suppliers
(1) Enrollment process
(A) In general
The Secretary shall establish by regulation a process for the
enrollment of providers of services and suppliers under this
subchapter.
(B) Deadlines
The Secretary shall establish by regulation procedures under
which there are deadlines for actions on applications for
enrollment (and, if applicable, renewal of enrollment). The
Secretary shall monitor the performance of medicare
administrative contractors in meeting the deadlines established
under this subparagraph.
(C) Consultation before changing provider enrollment forms
The Secretary shall consult with providers of services and
suppliers before making changes in the provider enrollment
forms required of such providers and suppliers to be eligible
to submit claims for which payment may be made under this
subchapter.
(2) Hearing rights in cases of denial or non-renewal
A provider of services or supplier whose application to enroll
(or, if applicable, to renew enrollment) under this subchapter is
denied may have a hearing and judicial review of such denial
under the procedures that apply under subsection (h)(1)(A) of
this section to a provider of services that is dissatisfied with
a determination by the Secretary.