Page:United States Statutes at Large Volume 111 Part 1.djvu/317

 PUBLIC LAW 105-33 —AUG. 5, 1997 111 STAT. 293 enrollee records) if the organization is accredited (and periodically reaccredited) by a private organization under a process that the Secretary has determined assures that the organization, as a condition of accreditation, applies and enforces standards with respect to the requirements involved that are no less stringent than the standards established under section 1856 to carry out the respective requirements. "(f) GRIEVANCE MECHANISM. — Each Medicare+Choice organization must provide meaningful procedures for hearing and resolving grievances between the organization (including any entity or individual through which the organization provides health care services) and enrollees with Medicare+Choice plans of the organization under this part. "(g) COVERAGE DETERMINATIONS, RECONSIDERATIONS, AND APPEALS.— "(1) DETERMINATIONS BY ORGANIZATION.— "(A) IN GENERAL.—^A Medicare+Choice organization shall have a procedure for making determinations regarding whether an individual enrolled with the plan of the organization under this part is entitled to receive a health service under this section and the amount (if any) that the individual is required to pay with respect to such service. Subject to paragraph (3), such procedures shall provide for such determination to be made on a timely basis. "(B) EXPLANATION OF DETERMINATION.—Such a determination that denies coverage, in whole in part, shall be in writing and shall include a statement in understandable language of the reasons for the denial and a description of the reconsideration and appeals processes. "(2) RECONSIDERATIONS.— "(A) IN GENERAL.— The organization shall provide for reconsideration of a determination described in paragraph (1)(B) upon request by the enrollee involved. The reconsideration shall be within a time period specified by the Secretary, but shall be made, subject to paragraph (3), not later than 60 days after the date of the receipt of the request for reconsideration. " (B) PHYSICIAN DECISION ON CERTAIN RECONSIDER- ATIONS.—A reconsideration relating to a determination to deny coverage based on a lack of medical necessity shall be made only by a physician with appropriate expertise in the field of me^^icine which necessitates treatment who is other than a physician involved in the initial determination. "(3) EXPEDITED DETERMINATIONS AND RECONSIDERATIONS. — "(A) RECEIPT OF REQUESTS. — "(i) ENROLLEE REQUESTS. —An enrollee in a Medicare+Choice plan may request, either in writing or orally, an expedited determination under paragraph (1) or an expedited reconsideration under paragraph (2) by the Medicare+Choice organization. "(ii) PHYSICIAN REQUESTS.^A physician, regardless whether the physician is affiliated with the organization or not, may request, either in writing or orally, such an expedited determination or reconsideration. " (B) ORGANIZATION PROCEDURES.—

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