Eliminating inefficiencies in administrative processing by Medicare Advantage organizations

(a) Applying fee-for-Service prompt payment requirements to MA in-Network services as well as out-of-Network services Section 1857(f)(1) of the Social Security Act (42 U.S.C. 1395w–27(f)(1)), as amended by section 4(a), is further amended— (1) in the paragraph heading, by inserting in-network and before out-of-network; and (2) by striking if the services or supplies and all that follows through the period at the end and inserting regardless of whether the services or supplies are furnished under a contract between the organization and the provider of services or supplier. A claim that is determined to be a clean claim pursuant to the previous sentence or paragraph (2) may not subsequently be determined to not be a clean claim except under such circumstances and in accordance with such criteria as specified by the Secretary pursuant to notice and comment rulemaking.. (b) Automated review and payment for certain claims Section 1857(f) of the Social Security Act (42 U.S.C. 1395w–27(f)), as amended by section 4(a), is further amended— (1) by redesignating paragraphs (3) and (4) as paragraphs (4) and (5), respectively; and (2) by inserting after paragraph (2) the following new paragraph: (3) Automated review and payment for certain claims (A) In general For plan years beginning on or after January 1, 2028, a Medicare Advantage organization shall have in place automated payment processes, in accordance with standards specified by the Secretary, for claims described in subparagraph (B) with respect to which the provisions of paragraph (1) or (2) apply. Such processes shall provide that such claims shall be automatically processed and paid and shall not be subject to manual claim review, except in cases for which there is reasonable evidence of fraud. (B) Specified claims For purposes of subparagraph (A), a claim described in this subparagraph is a claim that— (i) is for an authorized item or service (as defined in paragraph (2)(B)); or (ii) is for an item or service identified on the most recent list published pursuant to section 1852(g)(1)(D)(iii)..