The Center for Consumer Information and Insurance Oversight (CCIIO) released new guidance in November related to several stages of the No Surprises Act’s (NSA’s) Federal Independent Dispute Resolution (IDR) process.
- CCIIO announced that beginning the week of November 28th:
. . . a party seeking to initiate a payment dispute through the federal Independent Dispute Resolution (IDR) portal will be required to include certain documentation with the notice of initiation submission. Specifically, any party initiating a payment dispute must now upload the following:
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- Documents to confirm the open negotiation period start date (for example, the notice of open negotiation).
- Documents to confirm the claim and Qualifying Payment Amount information (i.e., the notices associated with the initial payment or notice of denial of payment).
Additionally, any party that enters an open negotiation start date more than 34 business days earlier than the date on which the form was completed must now upload documents to confirm that the claim is still eligible for the IDR process. The initiating party must upload at least one of the following:
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- Documents to confirm the extension approval received from the federal IDR mailbox.
- Documents to confirm the certified IDR entity’s request to re-submit the dispute due to batching or bundling errors.
- Documents to confirm the 90-day cooling off period has expired.
An entity that does not upload the required documentation will not be able to submit the notice of IDR initiation.
EDPMA has confirmed that this requirement to upload documentation related to the QPA does not preclude providers from initiating IDR in instances where the health plan has failed to make the required disclosures. In those cases, disputing parties should include the remittance advice or other documentation where you believe the QPA should have been disclosed had the health plan met its disclosure obligations. For departmental guidance on this topic, consult the August 2022 FAQs which state:
Q20: If a plan or issuer has failed to disclose the information it is required to provide when making an initial payment or sending a notice of denial of payment, may a provider, facility, or provider of air ambulance services initiate an open negotiation period and then proceed to the Federal IDR process?
Yes. In general, providers, facilities, and providers of air ambulance services have 30 business days from the day they receive an initial payment or a notice of denial of payment from the plan or issuer regarding an item or service to initiate open negotiation with respect to that item or service, including in cases in which information required to be provided is missing. However, a plan’s or issuer’s failure to satisfy the disclosure requirements in 26 CFR 54.9816-6T(d)(1) or (2), 26 CFR 54.9816-6(d)(1), 29 CFR 2590.716-6(d)(1) or (2), and 45 CFR 149.140(d)(1) or (2) could adversely affect a provider’s, facility’s, or provider of air ambulance services’ ability to meaningfully participate in negotiations during the open negotiation period and Federal IDR process.
In these cases, when a plan or issuer fails to comply with the disclosure requirements in 26 CFR 54.9816-6T(d)(1) or (2), 26 CFR 54.9816-6(d)(1), 29 CFR 2590.716-6(d)(1) or (2), and 45 CFR 149.140(d)(1) or (2), providers, facilities, or providers of air ambulance services retain the right to initiate the open negotiation period within 30 business days of receiving the initial payment or notice of denial of payment. In initiating the open negotiation period, the provider, facility, or provider of air ambulance services, must provide the standard open negotiation notice to the plan or issuer, as required in 26 CFR 54.9816-8T(b), 29 CFR 2590.716-8(b), and 45 CFR 149.140(b). After the 30-business-day open negotiation period has lapsed, the provider, facility, or provider of air ambulance services may initiate the Federal IDR process in accordance with the normal timelines.
Alternatively, in cases in which a plan or issuer fails to comply with the disclosure requirements in 26 CFR 54.9816-6T(d)(1) or (2), 26 CFR 54.9816-6(d)(1), 29 CFR 2590.716-6(d)(1) or (2), and 45 CFR 149.140(d)(1) or (2), providers, facilities, or providers of air ambulance services may request an extension to initiate the Federal IDR process, and provide applicable attestations, by emailing a request for extension due to extenuating circumstances to [email protected], including the time period(s) for which they are seeking an extension.
Failure by either party to supply information that is required to be submitted to the certified IDR entity (for example, failure to provide the QPA) may lead to a finding by the certified IDR entity that does not take into consideration the absent information, or may lead to the certified IDR entity drawing an inference about the absent information that is adverse to that party. Providers, facilities, and providers of air ambulance services with concerns about a plan’s or issuer’s compliance with the requirements of 26 CFR 54.9816-6T(d)(1), 26 CFR 54.9816- 6(d)(1), 29 CFR 2590.716-6(d)(1), and 45 CFR 149.140(d)(1), including concerns that a plan or issuer is not acting in good faith with respect to this requirement, may contact the No Surprises Help Desk at 1-800-985-3059 or submit a complaint at https://www.cms.gov/nosurprises/policies-and-resources/providers-submit-a-billing-complaint. The Departments will generally enforce the applicable provisions of the No Surprises Act, in conjunction with states where applicable. (Footnotes omitted).
- CCIIO released an updated document, Independent Dispute Resolution (IDR) Notice of Initiation Web Form, which can be accessed here, with the following highlighted changes:
- Requiring all initiating parties to submit the health plan type associated with the dispute. The plan should have provided this information when they submitted the initial payment or notice of denial of payment or during open negotiation. If the plan fails to provide this information to the provider, the provider may choose the No Plan/Issuer Response option.
- Requiring an initiating party that is a provider, facility, or a provider of air ambulance services to provide a Tax I.D. number or National Provider Identifier (NPI) number.
- Adding the ability for initiating parties to include mailing address and other contact information for additional points of contact.
EDPMA continues its close work with ACEP on implementation and advocacy related to the No Surprises Act and will continue to provide additional updates and information.