PROVISIONS RELATING TO THE ADMINISTRATION OF PART A^[20]

Sec. 1816. [42 U.S.C. 1395h] (a)[21] The administration of this part shall be conducted through contracts with medicare administrative contractors under section 1874A.

(b) [Repealed.^[22]]

(c)(1) [Stricken.^[23]]

(2)(A) Each contract under section 1874A that provides for making payments under this part^[24] shall provide that payment shall be issued, mailed, or otherwise transmitted with respect to not less than 95 percent of all claims submitted under this title—

(i) which are clean claims, and

(ii) for which payment is not made on a periodic interim payment basis,

within the applicable number of calendar days after the date on which the claim is received.

(B) In this paragraph:

(i) The term “clean claim” means a claim that has no defect or impropriety (including any lack of any required substantiating documentation) or particular circumstance requiring special treatment that prevents timely payment from being made on the claim under this title.

(ii) The term “applicable number of calendar days” means—

(I) with respect to claims received in the 12-month period beginning October 1, 1986, 30 calendar days,

(II) with respect to claims received in the 12-month period beginning October 1, 1987, 26 calendar days,

(III) with respect to claims received in the 12-month period beginning October 1, 1988, 25 calendar days,

(IV) with respect to claims received in the 12-month period beginning October 1, 1989, and claims received in any succeeding 12-month period ending on or before September 30, 1993, 24 calendar days, and

(V) with respect to claims received in the 12-month period beginning October 1, 1993, and claims received in any succeeding 12-month period, 30 calendar days.

(C) If payment is not issued, mailed, or otherwise transmitted within the applicable number of calendar days (as defined in clause (ii) of subparagraph (B)) after a clean claim (as defined in clause (i) of such subparagraph) is received from a hospital, critical access hospital, skilled nursing facility, home health agency, hospice program, comprehensive outpatient rehabilitation facility, or rehabilitation agency that is not receiving payments on a periodic interim payment basis with respect to such services, interest shall be paid at the rate used for purposes of section 3902(a) of title 31, United States Code^[25] (relating to interest penalties for failure to make prompt payments) for the period beginning on the day after the required payment date and ending on the date on which payment is made.

(3)(A) Each contract under section 1874A that provides for making payments under this part^[26] shall provide that no payment shall be issued, mailed, or otherwise transmitted with respect to any claim submitted under this title within the applicable number of calendar days after the date on which the claim is received.

(B) In this paragraph, the term “applicable number of calendar days” means—

(i) with respect to claims submitted electronically as prescribed by the Secretary, 13 days, and

(ii) with respect to claims submitted otherwise, 28 days^[27].

(d)- (i) [Repealed.^[28]]

(j) A contract with a medicare administrative contractor under section 1874A with respect to the administration of this part^[29] shall require that, with respect to a claim for home health services, extended care services, or post-hospital extended care services submitted by a provider to such agency or organization^[30] that is denied, such agency or organization—

(1) furnish the provider and the individual with respect to whom the claim is made with a written explanation of the denial and of the statutory or regulatory basis for the denial; and

(2) in the case of a request for reconsideration of a denial, promptly notify such individual and the provider of the disposition of such reconsideration.

(k) A contract with a medicare administrative contractor under section 1874A with respect to the administration of this part^[31] shall require that such medicare administrative contractor^[32] submit an annual report to the Secretary describing the steps taken to recover payments made for items or services for which payment has been or could be made under a primary plan (as defined in section 1862(b)(2)(A)).

(l) [Repealed.^[33]]

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^[20]  See Vol. II, P.L. 101-508, §4005(c)(3), with respect to guidance for intermediaries and hospitals.

P.L. 108-173, §911(b)(1), amended the heading for §1816 in its entirety, effective October 1, 2005. For the heading as it formerly read, see Vol. II, Appendix J, Superseded Provisions, P.L. 108-173.

^[21]  P.L. 108-173, §911(b)(2), amended subsection (a) in its entirety, effective October 1, 2005.

See Vol. II, P.L. 108-173, §911(d), with respect to the effective date and a transition rule.

For subsection (a) as it formerly read, see Vol. II, Appendix J, Superseded Provisions, P.L. 108-173.

^[22]  P.L. 108-173, §911(b)(3), repealed subsection (b), effective October 1, 2005.

See Vol. II, P.L. 108-173, §911(d), with respect to the effective date and a transition rule.

For subsection (b) as it formerly read, see Vol. II, Appendix J, Superseded Provisions, P.L. 108-173.

^[23]  P.L. 108-173, §911(b)(4)(A), struck out paragraph (1), effective October 1, 2005.

See Vol. II, P.L. 108-173, §911(d), with respect to the effective date and a transition rule.

For paragraph (1) as it formerly read, see Vol. II, Appendix J, Superseded Provisions, P.L. 108-173.

^[24]  P.L. 108-173, §911(b)(4)(B), struck out “agreement under this section” and substituted “contract under section 1874A that provides for making payments under this part”, effective October 1, 2005.

^[25]  See Vol. II, 31 U.S.C. 3902(a).

^[26]  P.L. 108-173, §911(b)(4)(B), struck out “agreement under this section” and substituted “contract under section 1874A that provides for making payments under this part”, effective October 1, 2005.

^[27]  P.L. 109-171, §5202(a)(1), struck out “26 days” and substituted “28 days”, applicable to claims submitted on or after January 1, 2006.

^[28]  P.L. 108-173, §911(b)(5), repealed subsections (d) through (i), effective October 1, 2005.

See Vol. II, P.L. 108-173, §911(d), with respect to the effective date and a transition rule.

For subsections (d) through (i) as they formerly read, see Vol. II, Appendix J, Superseded Provisions, P.L. 108-173.

^[29]  P.L. 108-173, §911(b)(6)(A), struck out “An agreement with an agency or organization under this section” and substituted “A contract with a medicare administrative contractor under section 1874A with respect to the administration of this part”, effective October 1, 2005.

^[30]  P.L. 108-173, §911(b)(6)(B), struck out “such agency or organization” and substituted “such medicare administrative contractor”, effective October 1, 2005.

^[31]  P.L. 108-173, §911(b)(6)(A), struck out “An agreement with an agency or organization under this section” and substituted “A contract with a medicare administrative contractor under section 1874A with respect to the administration of this part”, effective October 1, 2005.

^[32]  P.L. 108-173, §911(b)(6)(B), struck out “such agency or organization” and substituted “such medicare administrative contractor”, effective October 1, 2005.

^[33]  P.L. 108-173, §911(b)(7), repealed subsection (l), effective October 1, 2005.

See Vol. II, P.L. 108-173, §911(d), with respect to the effective date and a transition rule.

For subsection (l) as it formerly read, see Vol. II, Appendix J, Superseded Provisions, P.L. 108-173.