IDR Entity Certification and IDR Entity Monthly Reporting

OMB Control Number: 0938-NEW

Expiration Date: XX/XXXX

APPENDIX 5

Patient-Provider Selected Dispute Resolution (SDR) Entity Certification Application

Data Elements

The Departments of the Treasury, Labor and Health and Human Services (the Departments) have issued the Requirements Related to Surprise Billing; Part II interim final rule (86 FR 55980), which provides protections for the uninsured. This rule requires the Secretary of HHS to establish a process referred to as the patient-provider dispute resolution process. Under this process, an uninsured (or self-pay) individual may seek a determination from an SDR entity for any billed charges from a provider¹ or facility that are substantially in excess of the good faith estimate provided by that health care provider or facility in advance of receiving the items or services. These requirements provide for an SDR entity to review and make an independent, binding determination of the payment amount for items and services. The SDR entity must be certified by the Secretary under 45 CFR 149.620(d). HHS intends to contract with between 1 and 3 SDR entities that meet the certification requirements outlined in 45 CFR 149.620(d), rather than pursue an open certification process as is the case for certified Independent Dispute Resolution (IDR) entities in the federal IDR process.

The table below identifies data elements that an organization seeking to become an SDR entity is required to include in the contracting process.

DATA ELEMENT	DESCRIPTION
SDR Entity Application for Certification
General Company Information
Legal SDR entity Name and trade name (DBA) if applicable	SDR entity’s legal name as written on their business license, and DBA if applicable
SDR entity Address	SDR entity’s physical address, including street name and number, city, state, and zip code
SDR entity Website	SDR entity’s uniform resource locator (URL) linked to the home webpage (e.g., www.SDR entity.org)
Tax ID Type and Number	SDR entity’s taxpayer identification number (TIN), employer identification number (EIN), or federal tax identification number (FEIN) issued by the Internal Revenue Service, and type of number
Primary Contact Information	First name, last name, phone number, and email address of the person representing the SDR entity on the application
Secondary Contact Information	First name, last name, phone number, and email address of an additional person, other than the primary contact, representing the SDR entity on the application.
Expertise
Documentation to prove expertise	Verification (e.g., staff members’ resumes or CVs showing experience) that SDR entity has requisite medical and legal expertise, including in health care and air-space laws, and sufficient experience in arbitration and claims administration, managed care, and billing and coding. Additional documentation of expertise and other supporting materials may be submitted for consideration.*
Organization Structure and Staffing Plan
Organization Chart	A graphic representation of the structure of the SDR entity showing the hierarchy of the organization and the relationships within it, including any parent or subsidiary entities. SDR entities must not be owned by a subsidiary of, or associated or affiliated with a plan, issuer, provider, provider of air ambulance services.
Staffing Plan	Document that describes the credentials, responsibilities, and number of personnel employed to make determinations. This should also include policies and procedures governing the allocation of staff to case arbitration, including the credentials and responsibilities of staff that will be arbitrating cases, as well as policies and procedures for ensuring proper verification of credentials. Documentation should also show operations and infrastructure to effectively and efficiently manage the arbitration process, including delegation of functions and oversight of the process, and applicable procedures for using contractors to fill expertise vacancies so determinations can be completed within the required time period.
Conflict of Interest Attestation
Organizational Attestation of No Conflicts of Interest	An attestation indicating the SDR entity is not (1) a provider or a facility; (2) not an affiliate or subsidiary of a provider or a facility; or (3) an affiliate or subsidiary of a professional or trade association representing providers or facilities.
Indicators of Fiscal Integrity and Stability
Documentation to prove fiscal integrity and stability	Documentation describing a system of safeguards and controls in place to prevent and detect improper financial activities by employees and other affiliated persons to assure the fiscal integrity and accountability for all fees received and held, and three most recent years of SDR entity’s balance sheets, income statements, cash flow statements, and statements of changes in owners’ equity (if applicable) or other documentation to demonstrate fiscal stability.
Internal Controls to Hold Fees
Internal Controls to Hold Administrative Fees	Policies and procedures to retain the administrative fees paid by the initiating party during the initiation of the dispute resolution process, remit funds to CMS, and prevent fraud, abuse, or waste of funds held.
Conflict of Interest Audit Standards
Conflict of Interest Mitigation Policies	Information on the SDR entity’s conflict-of-interest policies and procedures, including outlining a mitigation plan in the event of an entity-level conflict of interest, under which no dispute resolution personnel affiliated with the SDR entity can fairly and impartially adjudicate a case, in compliance with the standards in Federal Acquisition Regulation subpart 9.5
Proof of Accreditation or Arbitration Training
Document(s) to demonstration proof of Accreditation or Arbitration Training	Documentation proving current accreditation by a certified accreditation body, such as URAC, or that the SDR entity otherwise possesses the requisite training to conduct payment determinations (for example, providing documentation that personnel have competed arbitration training by the American Arbitration Association, American Health Law Association, or a similar organization).
Confidential Health Information
Confidential Health Information Standards	Written policies and procedures to protect the confidentially of IIHI as outlined in the interim final rules for Requirements Related to Surprise Billing: Part II, including how the certified SDR Entity will: ensure the confidentiality, integrity, and availability of all IIHI they create, obtain, maintain, store, or transmit; protect against any reasonably anticipated threats or hazards to the security or integrity of IIHI; protect against unauthorized use or disclosure of IIHI by their personnel; securely destroy or dispose of IIHI; monitor, periodically assess, and update security controls and related systems risks to ensure the continued effectiveness of those controls; and in the event of a breach in unsecure IIHI, conduct a risk assessment to determine the nature and extent of the breach, and provide notifications to the Departments and all parties affected by the breach.
Internal Controls to Support Reporting Compliance
Reporting Plan	Policies and procedures outlining your organization’s ability to comply with reporting requirements found in the SDR entity’s contract with CMS, including properly collecting and storing all required information and how this will be reported to the Departments.
Policies and Procedures for Subcontracting
Subcontractor Management Plan	Documentation describing the organization’s policies and procedures for managing subcontractors, including how the organization will ensure that subcontractors assigned to a determination do not have a conflict of interest regarding any party to the dispute, and how the organization will ensure that subcontractors protect IIHI, in the same manner as required of certified SDR entities.
Policies and Procedures for Compliance with Federal Civil Rights Laws
Nondiscrimination Policies and Procedures	Policies and procedures for ensuring compliance with federal civil rights laws that prohibit discrimination to the extent applicable, including section 1557 of the Affordable Care Act, title VI of the Civil Rights Act of 1964, sections 504 and 508 of the Rehabilitation Act of 1973.
Contract with Secretary to Meet Certified SDR Entity Standards and Procedures
Standards and Procedures as Determined by the Secretary	Contract detailing standards and procedures determined by the Secretary through guidance for SDR entities.

*Denotes optional submission

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 1210-0169. The time required to complete this information collection is estimated to average of 5.25 hours per respondent, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

PRIVACY ACT STATEMENT:  CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to:  (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entity’s compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.

1 For ease of reference, for purposes of this document, the term “provider” should be considered to include providers of air ambulance services.

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