DENIALS AND RECONSIDERATIONS OF CLAIMS FOR HOME HEALTH SERVICES, EXTENDED CARE SERVICES, AND POSTHOSPITAL EXTENDED CARE SERVICES.

SEC. 4032. DENIALS AND RECONSIDERATIONS OF CLAIMS FOR HOME HEALTH SERVICES, EXTENDED CARE SERVICES, AND POSTHOSPITAL EXTENDED CARE SERVICES. (a) Notification and Physician Review.— Section 1816 of the Social Security Act (42 U.S.C. 1395h) is amended by adding at the end the following new subsection: “(j) An agreement with an agency or organization under this section 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 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) promptly notify such individual and the provider of disposition of such reconsideration.”. 101 STAT. 1330–77 (b) Performance Standards for Fiscal Intermediaries and Carriers.— Section 1816(f) of such Act (42 U.S.C. 1395h(f)) is amended by adding at the end the following: “Such standards and criteria shall include with respect to claims for services furnished under this part by any provider of services other than a hospital whether such agency or organization is able to process 75 percent of reconsiderations within 60 days (except in the case of the fiscal year 1989, 66 percent of reconsiderations) and 90 percent of reconsiderations within 90 days and the extent to which its determinations are reversed on appeal.”. (c) Effective Date.— (1) (A) The amendment made by subsection (a) shall apply with respect to claims received on or after January 1, 1988. (B) The amendment made by subsection (b) shall apply with respect to claims filed on or after October 1, 1988. (2) The Secretary of Health and Human Services shall provide for such timely amendments to agreements under section 1816 and contracts under section 1842 of the Social Security Act, and regulations, to such extent as may be necessary to implement the amendments made by subsections (a) and (b) on a timely basis.