Page:United States Statutes at Large Volume 100 Part 3.djvu/184

 100 STAT. 1992

42 USC 1395y.

qj

42 USC 1395h. 42 USC I395f. 42 USC I395n.

42 USC I395pp note. 42 USC 1395. Ante, p. 1991.

PUBLIC LAW 99-509—OCT. 21, 1986

(C) in the third sentence of subsection (a), by inserting "or by reason of a coverage denial described in subsection (g)" after "section 1862(a)(1) or (9)"; (D) in subsection (c), by inserting "or by reason of a coverage denial described in subsection (g)" after "section 1862(a)(1) or (9)"; and (E) by adding at the end the following new subsections: "(f)(1) A home health agency which meets the applicable requirements of paragraphs (3) and (4) shall be presumed to meet the requirement of subsection (a)(2) with respect to any coverage denial described in subsection (g). "(2) The presumption of paragraph (1) with respect to specific services may be rebutted by actual or imputed knowledge of the facts described in subsection (a)(2), including any of the following: "(A) Notice by the fiscal intermediary of the fact that payment may not be made under this title with respect to the services. "(B) It is clear and obvious that the provider should have known at the time the services were furnished that they were excluded from coverage. "(3) The requirements of this paragraph are as follows: "(A) The agency complies with requirements of the Secretary under this title respecting timely submittal of bills for payment and medical documentation. "(B) The agency program has reasonable procedures to notify promptly each patient (and the patient's physician) where it is determined that a patient is being or will be furnished items or services which are excluded from coverage under this title. "(4) The requirement of this paragraph is that, on the basis of bills submitted by a home health agency during the previous quarter, the rate of denial of bills for the agency by reeison of a coverage denial described in subsection (g) does not exceed 2.5 percent, computed based on visits for home health services billed. "(5) In this subsection, the term 'fiscal intermediary' means, with respect to a home health agency, an agency or organization with an agreement under section 1816 with respect to the agency. "(g) The coverage denial described in this subsection is, with respect to the provision of home health services to an individual, a failure to meet the requirements of section 1814(a)(2)(C) or section 1835(a)(2)(A) in that the individual— "(1) is or was not confined to his home, or "(2) does or did not need skilled nursing care on an intermittent basis." (2) REPORTS.—The Secretary of Health and Human Services shall report to Congress annually in March of 1987 and 1988— (A) information on the frequency and distribution (by type of provider) of denials of bills for payment under title ' XVIII of the Social Security Act for extended care services, home health services, and hospice care, by reason of section 1862(a)(1) or (9) of such Act and coverage denials described in section 1879(g) of such Act, including— i (i) the reasons for such denials, (ii) the extent to which payments were nonetheless made because of section 1879 of such Act, and (iii) the rate of reversals of such denials, and (B) such other information as may be appropriate to evaluate the appropriateness of any percentage standards

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