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US Laws | Affordable Health Care Act (HR3950F)
TITLE VI--TRANSPARENCY AND PROGRAM INTEGRITY
Subtitle F--Additional Medicaid Program Integrity Provisions

"(A) has unpaid overpayments (as defined by the Secretary) under this title during such period determined by the Secretary or the State agency to be delinquent; (10212)

"(B) is suspended or excluded from participation under or whose participation is terminated under this title during such period; or (10213)

"(C) is affiliated with an individual or entity that has been suspended or excluded from participation under this title or whose participation is terminated under this title during such period;". (10214)

SEC. 6503. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE PAYEES REQUIRED TO REGISTER UNDER MEDICAID. (10215)(Text)

(a) In General- Section 1902(a) of the Social Security Act (42 U.S.C. 42 U.S.C. 1396a(a)), as amended by section 6502(a), is amended by inserting after paragraph (78), the following: (10216)

"(79) provide that any agent, clearinghouse, or other alternate payee (as defined by the Secretary) that submits claims on behalf of a health care provider must register with the State and the Secretary in a form and manner specified by the Secretary;". (10217)

SEC. 6504. REQUIREMENT TO REPORT EXPANDED SET OF DATA ELEMENTS UNDER MMIS TO DETECT FRAUD AND ABUSE. (10218)(Text)

(a) In General- Section 1903(r)(1)(F) of the Social Security Act (42 U.S.C. 1396b(r)(1)(F)) is amended by inserting after "necessary" the following: "and including, for data submitted to the Secretary on or after January 1, 2010, data elements from the automated data system that the Secretary determines to be necessary for program integrity, program oversight, and administration, at such frequency as the Secretary shall determine". (10219)

(b) Managed Care Organizations- (10220)

(1) IN GENERAL- Section 1903(m)(2)(A)(xi) of the Social Security Act (42 U.S.C. 1396b(m)(2)(A)(xi)) is amended by inserting "and for the provision of such data to the State at a frequency and level of detail to be specified by the Secretary" after "patients". (10221)

(2) EFFECTIVE DATE- The amendment made by paragraph (1) shall apply with respect to contract years beginning on or after January 1, 2010. (10222)

SEC. 6505. PROHIBITION ON PAYMENTS TO INSTITUTIONS OR ENTITIES LOCATED OUTSIDE OF THE UNITED STATES. (10223)(Text)

Section 1902(a) of the Social Security Act (42 U.S.C. 1396b(a)), as amended by section 6503, is amended by inserting after paragraph (79) the following new paragraph: (10224)

"(80) provide that the State shall not provide any payments for items or services provided under the State plan or under a waiver to any financial institution or entity located outside of the United States;". (10225)

SEC. 6506. OVERPAYMENTS. (10226)(Text)

(a) Extension of Period for Collection of Overpayments Due to Fraud- (10227)

(1) IN GENERAL- Section 1903(d)(2) of the Social Security Act (42 U.S.C. 1396b(d)(2)) is amended-- (10228)

(A) in subparagraph (C)-- (10229)

(i) in the first sentence, by striking "60 days" and inserting "1 year"; and (10230)

(ii) in the second sentence, by striking "60 days" and inserting "1-year period"; and (10231)

(B) in subparagraph (D)-- (10232)

(i) in inserting "(i)" after "(D)"; and (10233)

(ii) by adding at the end the following: (10234)

"(ii) In any case where the State is unable to recover a debt which represents an overpayment (or any portion thereof) made to a person or other entity due to fraud within 1 year of discovery because there is not a final determination of the amount of the overpayment under an administrative or judicial process (as applicable), including as a result of a judgment being under appeal, no adjustment shall be made in the Federal payment to such State on account of such overpayment (or portion thereof) before the date that is 30 days after the date on which a final judgment (including, if applicable, a final determination on an appeal) is made.". (10235)

(2) EFFECTIVE DATE- The amendments made by this subsection take effect on the date of enactment of this Act and apply to overpayments discovered on or after that date. (10236)

(b) Corrective Action- The Secretary shall promulgate regulations that require States to correct Federally identified claims overpayments, of an ongoing or recurring nature, with new Medicaid Management Information System (MMIS) edits, audits, or other appropriate corrective action. (10237)

SEC. 6507. MANDATORY STATE USE OF NATIONAL CORRECT CODING INITIATIVE. (10238)(Text)

Section 1903(r) of the Social Security Act (42 U.S.C. 1396b(r)) is amended-- (10239)

(1) in paragraph (1)(B)-- (10240)

(A) in clause (ii), by striking "and" at the end; (10241)

(B) in clause (iii), by adding "and" after the semi-colon; and (10242)

(C) by adding at the end the following new clause: (10243)

"(iv) effective for claims filed on or after October 1, 2010, incorporate compatible methodologies of the National Correct Coding Initiative administered by the Secretary (or any successor initiative to promote correct coding and to control improper coding leading to inappropriate payment) and such other methodologies of that Initiative (or such other national correct coding methodologies) as the Secretary identifies in accordance with paragraph (4);"; and (10244)

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