An announcement from Centers for Medicare and Medicaid Services (CMS) regarding last Friday’s, April 15th, opening of the Independent Dispute Resolution (IDR) process, which allows providers (including air ambulance providers), facilities, and health plans and issuers to resolve payment disputes for certain out-of-network charges and initiate the IDR process under the No Surprises Act.  For claims in which the open negotiations period expired prior to the portal opening, providers now have 15 business days, until May 6th, to initiate the IDR process.  For claims currently in the open negotiations period, the standard timelines will apply (i.e. the IDR process must be initiated within 4 business days of the open negotiations period ending).  The IDR portal can be accessed here.

After the end of a 30-business day open negotiation period where all parties in good faith try to reach an out-of-network payment agreement, a provider, facility, health plan or issuer can use the online portal to initiate the Federal IDR process.

To start a dispute, an initiating party will need:

  • Information to identify the qualified IDR items or services;
  • Dates and location of items or services;
  • Type of items or services such as emergency services and post-stabilization services;
  • Codes for corresponding service and place-of-service;
  • Attestation that items or services are within the scope of the Federal IDR process; and
  • The initiating party’s preferred certified IDR entity. A list of certified entities can be found here.

At the end of the 30-business-day open negotiation period, initiating parties have 4 business days to initiate a dispute via the portal. As a result of the recent decision in Texas Medical Ass’n, et al. v HHS, the Departments will give disputing parties whose open negotiation period expired before today, April 15, 2022, 15 business days to file an initiation notice via the IDR Portal.

Even after starting the Federal IDR process, disputing parties can continue to negotiate until the IDR entity makes a determination. If the parties reach an agreement on the out-of-network payment rate, they should email the certified IDR entity and the Departments (at FederalIDRQuestions@cms.hhs.gov) and attach a document that contains the following:

  1. The agreed-upon out-of-network rate for the qualified IDR item, batched determinations, or service (that is, the total payment amount, including both participant, beneficiary, or enrollee cost sharing and the total plan or coverage payment, including amounts already paid);
  2. Allocation of how parties agree to pay certified IDR entity fee (if parties choose not to evenly split the fee); and
  3. Signatures from authorized signatories for both the initiating and the non-initiating party.

This information must be submitted within 3 business days of the agreement.

If the disputing parties experience extenuating circumstances during the IDR process that prohibit them from complying with deadlines to submit information, they may email the Departments (at FederalIDRQuestions@cms.hhs.gov) to receive a Request for Extension Due to Extenuating Circumstances form and instructions for next steps.

To learn more about the Independent Dispute Resolution process, including to read guidance materials, FAQs, and model notices, visit www.cms.gov/nosurprises

Additional information and resources:

  • CMS resources on the No Surprises Act are available here.
  • CMS webinar held earlier this week to walk stakeholders through the IDR process.
  • CMS released guidance for disputing parties earlier this week.
  • CMS also released revised guidance to IDR entities detailing the IDR process and requiring the arbiters to consider a series of factors when making a payment determination without giving undue weight to the plan’s median in-network rate or Qualifying Payment Amount (QPA).
  • The AMA recently released a toolkit outlining the payment process.  (It will be updated shortly with the newly released IDR information.)
  • Additional AMA resources, letters, and litigation updates on the No Surprises Act available here.
  • Sign up for an AMA webinar on the out-of-network payment process under the No Surprises Act here.  The webinar will take place on April 21st at 11:30am CT.