The Departments of Health and Human Services, Labor, and the Treasury and the Office of Personnel Management released a fact sheet on Oct. 27 detailing the No Surprises Act (NSA) Independent Dispute Resolution (IDR) Process proposed rule.
The proposed rule includes new requirements for group health plans and health insurance issuers; providers, facilities, and providers of air ambulance services; and certified IDR entities as they relate to the Federal IDR process under the NSA. Additionally, the proposed rule considers specific issues identified through feedback from interested parties that are critical to improving the functioning of the Federal IDR process.
The fact sheet outlines key objectives of the proposed rule. If finalized, the proposed rule would:
- improve communication between payers, providers, and certified IDR entities by requiring payers to disclose important information about the claim, including the qualifying payment amount and contact information for initiating the open negotiation period. Additionally, payers would be required to use specific claim adjustment reason codes and remittance advice remark codes when they provide any paper or electronic remittance advice to an entity that does not have a contractual relationship with the payer.
- adjust specific timelines and steps of the Federal IDR process, requiring that a party provide an open negotiation notice to the other party and the Departments through the Federal IDR portal to initiate the open negotiation period, and that an open negotiation response notice be furnished by the party in receipt of the open negotiation notice to the other party and the Departments by the 15th business day of the 30-business-day open negotiation period.
- establish new batching provisions that would allow greater flexibility for which items and services can be batched in a single dispute, while also limiting batched determinations to 25 qualified IDR items and services in a single dispute to ensure certified IDR entities can make timely eligibility and payment determinations.
- require certified IDR entities to determine eligibility within five business days of final certified IDR entity selection and notify both disputing parties and the Departments.
- streamline the collection of administrative fees from the disputing parties by having the Departments collect the nonrefundable administrative fee directly from the disputing parties rather than having the certified IDR entities collect the administrative fee on the Departments’ behalf. The Departments also propose that the initiating party be required to pay the administrative fee within two business days of the date of preliminary certified IDR entity selection, while the noninitiating party would be required to pay within two business days of receiving a notice of an eligibility determination.
- amend the extenuating circumstances in which the time periods may be extended by the Departments to include events that contribute to systematic delays in processing disputes under the Federal IDR process, such as an unforeseen volume of disputes or Federal IDR portal system failures.
- and require payers subject to the Federal IDR process to register with the Departments and provide general information on the applicability of the Federal IDR process to items or services covered by the plan or coverage.
As stated in the fact sheet, “It is the Departments’ intention that together, these proposals would result in improved operations of the Federal IDR process and more timely payment determinations.”
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