Page:United States Statutes at Large Volume 91.djvu/1210

 91 STAT. 1176

State plans for medical lo^^TT^r'i !»o^ 139oa.

Effective date. 42 USC 1395g '**>*®-

Claims payment procedures.

PUBLIC LAW 95-142—OCT. 25, 1977 ments or the billings therefor, and is not dependent upon the actual collection of any such payment.". (3) Section 1902(a) (32) of such Act is amended to read as follows: "(32) provide that no payment under the plan for any care or service provided to an individual shall be made to anyone other than such individual or the person or institution providing such care or service, under an assignment or power of attorney or otherwise; except that— "(A) in the case of any care or service provided by a physician, dentist, or other individual practitioner, such payment may be made (i) to the employer of such physician, dentist, or other practitioner if such physician, dentist, or practitioner is required as a condition of his employment to turn over his fee for such care or service to his employer, or (ii) (where the care or service was provided in a hospital, clinic, or other facility) to the facility in which the care or service was provided if there is a contractual arrangement between such physician, dentist, or practitioner and such facility under which such facility submits the bill for such care or service; and "(B) nothing in this paragraph shall be construed (i) to prevent the making of such a payment in accordance with an assignment from the person or institution providing the care or service involved if such assignment is made to a governmental agency or entity or is established by or pursuant to the order of a court of competent jurisdiction, or (ii) to preclude an agent of such person or institution from receiving any such payment if (but only if) such agent does so pursuant to an agency agreement under which the compensation to be paid to the agent for his services for or in connection with the billing or collection of payments due such person or institution under the plan is unrelated (directly or indirectly) to the amount of such payments or the billings therefor, and is not dependent upon the actual collection of any such payment;". (4) The amendments made by this subsection shall apply with respect to care and services furnished on or after the date of the enactment of this Act. (b)(1) Section 1902(a) of the Social Security Act is amended— (A) by striking out "and" at the end of paragraph (35); (B) by striking out the period at the end of paragraph (36) and inserting in lieu thereof "; and"; (C) by inserting immediately after paragraph (36) the foliowjng new paragraph: "(37) provide for claims payment procedures which (A) ensure that 90 per centum of claims for payment (for which no further written information or substantiation is required in order to make payment) made for services covered under the plan and furnished by health care practitioners through individual or group practices or through shared health facilities are paid within 30 days of the date of receipt of such claims and that 99 per centum of such claims are paid within 90 days of the date of receipt of such claims, and (B) provide for procedures of prepayment and postpayment claims review, including review of appropriate data with respect to the recipient and provider of a service and the nature of the service for which payment is claimed, to ensure the proper and efficient payment of claims and management of the program."; and

�