IDR
Entity Application for Certification
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General
Company Information
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Legal
IDR Entity Name and Preferred Business Name, if Applicable
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IDR
entity’s business name as written on their business
license, and preferred business name if applicable.
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IDR
Entity Address
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IDR
entity’s physical address (and mailing address if
different), including street name and number, city, state, and
zip code.
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IDR
Entity Website
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IDR
entity’s uniform resource locator (URL) linked to the home
webpage (e.g., www.IDRentity.org).
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Tax
ID Number
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IDR
entity’s taxpayer identification number (TIN), employer
identification number (EIN), or Federal tax identification number
(FTIN) issued by the Internal Revenue Service.
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Primary
Contact Information
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First
name, last name, phone number, and email address of the person
representing the IDR entity on the application.
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Secondary
Contact Information
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First
name, last name, phone number, and email address of an additional
person, other than the primary contact, representing the IDR
entity on the application.
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Service
Area
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IDR
Service Area
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All
states, including DC and U.S. Territories, where the IDR entity
legally operates and intends to provide IDR services under the
Federal IDR process.
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Expertise
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Documentation
to Demonstrate Expertise
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Verification
(e.g., staff members’ resumes or CVs showing experience or
contracts or other arrangements showing experience) that IDR
entity has sufficient medical and legal expertise, and sufficient
experience in arbitration and claims administration of health
care services, managed
care, and billing and coding. Additional non-mandatory
documentation of expertise may be submitted optionally for
consideration as desired.*
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Organization
Structure and Staffing Plan
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Organization
Chart
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A
graphic representation of the organizational structure and
capabilities of the IDR entity, including an organizational chart
and the credentials, responsibilities, and number of personnel
employed to make determinations.
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Staffing
Plan
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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.
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Conflict
of Interest Attestation
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Organizational
Attestation of No Conflicts of Interest
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An
attestation indicating the IDR entity is (1) not a group health
plan; a health insurance issuer offering group health insurance
coverage, individual health insurance coverage, or short-term,
limited-duration insurance; an FEHB carrier; or a provider, a
facility, or a provider of air ambulance services; (2) not an
affiliate or a subsidiary of a group health plan; a health
insurance issuer offering group health insurance coverage,
individual health insurance coverage, or short-term
limited-duration insurance; an FEHB carrier; or a provider, a
facility, or a provider of air ambulance services; and (3) not an
affiliate or subsidiary of a professional or trade association
representing group health plans; health insurance issuers
offering group health insurance coverage, individual health
insurance coverage, or short-term limited duration insurance;
FEHB carriers; or providers, facilities, or providers of air
ambulance services.
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Process
to Ensure No Conflicts of Interest
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Process
to ensure that an IDR entity, certified IDR entity or any
personnel assigned to a determination does not have a material
familial, financial, or professional relationship with a party to
the payment determination being disputed, or with any officer,
director, or management employee of the plan, issuer, or FEHB
carrier; the plan administrator, plan fiduciaries, or plan,
issuer, or FEHB carrier employees; the health care provider, the
health care provider's group or practice association; the
provider of air ambulance services, the provider of air ambulance
services’ group or practice association, or the facility
that is a party to the dispute. This includes policies and
procedures for conducting ongoing audits for conflicts of
interest, to ensure that should any arise, the certified IDR
entity has procedures in place to inform the Departments of the
conflict of interest and to mitigate the risk by reassigning the
dispute to other personnel in the event that any personnel
previously assigned have a conflict of interest.
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Indicators
of Fiscal Integrity and Stability
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Documentation
to Demonstrate Fiscal Integrity and Stability
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Three
most recent years of IDR entity’s financial statements,
including balance sheets, income statements, cash flow
statements, and statements of changes in owners’ equity, or
information to otherwise demonstrate fiscal stability.
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Internal
Controls to Hold Fees
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Internal
Controls to Hold Certified IDR Entity Fees and Administrative
Fees
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Policies
and procedures to retain the certified IDR entity fees and
administrative fees paid by both parties during the initiation of
the Federal IDR process and to return funds as necessary to the
prevailing party, and remit funds to CMS.
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Fee
Schedule
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Standard
Fee for Non-Batched Arbitration
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Amount
an IDR entity will charge for arbitration of items and services
on a single bill.
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Standard
Fee for Batched Arbitration
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Amount
an IDR entity will charge for arbitration of multiple qualified
IDR items or services that are considered jointly as part of a
single determination by a certified IDR entity for purposes of
the Federal IDR process.
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Fee
Within Set Range Confirmation
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Confirmation
whether or not standard fees for non-batched and batched
arbitration are within the range set by the Departments.
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Alternate
Fee Justification
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Description
of the circumstances that require the alternate fee.
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Description
of Mitigation
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Description
of how the alternate fee will be used to mitigate the effect of
these circumstances.
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Proof
of Accreditation or Training
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Document(s)
to Demonstrate Proof of Accreditation or Training
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Documentation
to show the IDR entity is accredited by a nationally recognized
and relevant accrediting organization, such as URAC, or ensure
that it otherwise possesses the requisite training to conduct
payment determinations (for example, providing documentation that
personnel employed by the IDR entity have completed arbitration
training by the American Arbitration Association, the American
Health Law Association, or a similar organization).
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Confidential
Health Information
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Confidential
Health Information Standards
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Process
to ensure confidentiality and protection of individually
identifiable health information (IIHI).
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Reporting
Requirements
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Reporting
Plan
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Documentation
describing IDR entity’s ability to comply with reporting
requirements to the Departments.
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Policies
and Procedures for Subcontracting
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Subcontractor
Management Plan
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Policies
and procedures for managing subcontractors.
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Attestation
of Compliance
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Attestation
that the IDR entity will oversee subcontractor compliance with
IDR entity certification requirements, including requirements
ensuring confidentiality and protection of IIHI.
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Post-Application
and Post-Certification Documentation
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IDR
Entity Response to Petition and Appeal of Denial or Revocation
Decision (if applicable)
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Response
to Petition
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If
a petition to deny or revoke certification adequately shows a
failure to follow the certification requirements or any other
failures identified in the interim final rules at 26 CFR
54.9816-8T(e), 29 CFR 2590.716-8(e), and 45 CFR 149.510(e) the
Departments will notify the IDR entity requesting certification
or the certified IDR entity by providing a de-identified copy of
the petition. Following the notification, the IDR entity or
certified IDR entity will have 10 business days to provide a
response.
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Request
for a Hearing to Appeal the Denial or Revocation Decision of the
Secretary
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An
IDR entity may appeal the denial of certification decision and a
certified IDR entity may appeal the revocation of certification
decision by filing a request for hearing under an applicable
administrative hearing process within 30 business days of the
date of the written denial or revocation. The IDR entity who
files a request for a hearing must provide sufficient additional
documentation and justification to the Departments to overcome
the purpose of denial or revocation.
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