8. Tri-dept - notice of petition for certification denial or revocation clean 9.28.21

OMB Control Number XXX-XXX

Expiration Date: XX/XX/XXXX

Petition to Deny or Revoke IDR Certification

Instructions

The Departments of Health and Human Services, Labor, and the Treasury (the Departments), and the Office of Personnel Management have issued interim final rules establishing a Federal independent dispute resolution process (Federal IDR process) that group health plans, health insurance issuers offering group or individual insurance coverage or Federal Employees Health Benefits (FEHB) carriers and out-of-network or nonparticipating health care facilities and providers, and providers of air ambulance services may utilize following the end of an open negotiation period. The Federal IDR process is available only for certain services, such as out-of-network emergency services, certain services provided by out-of-network providers at an in-network facility, or air ambulance services. The Federal IDR process is also only available if a state All-Payer Model Agreement or specified state law does not apply; otherwise, the state All-Payer Model Agreement or law applies. Additionally, a party may not initiate the Federal IDR process if, with respect to an item or service, the party knows or reasonably should have known that the provider or facility provided notice and obtained consent from a participant, beneficiary, or enrollee to waive surprise billing protections consistent with PHS Act sections 2799B-1(a) and 2799B-2(a) and the implementing regulations at 45 CFR 149.410(b) and 149.420(c)-(i).  

An IDR entity must meet certain standards and be certified by the Departments in order to be selected for the Federal IDR process. The Departments have established a process to certify IDR entities, with certification being effective for a 5-year period. In order to be certified, IDR entities must provide written documentation demonstrating that they meet the eligibility criteria. For example, IDR entities must demonstrate they have sufficient expertise in arbitration and claims administration of health care services, managed care, billing, coding, medical matters, and legal matters; have a sufficient number of personnel to make determinations within 30 business days; maintain a current accreditation from a nationally-recognized accreditation 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); and ensure that no conflicts of interest exist between the parties and the IDR entity or the personnel the IDR entity assigns to each dispute. Certain plans, issuers, FEHB carriers, providers, providers of air ambulance services, facilities, and their affiliates and subsidiaries (as well as professional or trade associations representing plans, issuers, providers, providers of air ambulance services, facilities and their applicable affiliates and subsidiaries) are prohibited from being certified IDR entities. For a complete list of the certification standards and requirements see 26 CFR 54.9816-8T(e), 29 CFR 2590.716-8(e), and 45 CFR 149.510(e).

An individual, provider, provider of air ambulance services, facility, plan, issuer, or FEHB carrier may petition for the denial of certification for an IDR entity seeking certification or revocation of a certification of a certified IDR entity. The petitioner requesting the denial or revocation of certification must use the attached form to submit the petition and attach any documentation to support the reasons for the request for the denial or revocation. The Departments will acknowledge receipt of the petition within 10 business days of receipt of the petition.

NOTE: Parties do not need to include this instruction page with the petition.

Paperwork Reduction Act Statement 

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number.  The Departments and OPM note that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number.  See 44 U.S.C. 3507.  Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number.  See 44 U.S.C. 3512. 

The public reporting burden for this voluntary collection of information is estimated to be 2 hours and 15 minutes per response, including time for reviewing general information about requesting assistance, gathering information, completing and reviewing the collection of information, and uploading attachments if applicable.  Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Regulations and Interpretations, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number XXXX-XXXX.  Note: Please do not return the completed request for assistance to this address. 

OMB Control Number XXX-XXX

Expiration Date: XX/XX/XXXX

Petition to Deny or Revoke IDR Certification

[Enter date of notice]

I am submitting this petition requesting that the Departments deny or revoke the certification of an independent dispute resolution (IDR) entity, as provided below, pursuant to Internal Revenue Code section 9816(c), Employee Retirement Income Security Act section 716(c), and Public Health Service Act section 2799A-1(c).

INFORMATION TO BE COMPLETED BY PETITIONER

1. Identity of the certified IDR entity or IDR entity seeking certification that is the subject of this petition (specify the name and the certified IDR entity number, if available):

__________________________________________________________________________

2. The reason(s) for the petition:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

3. Whether the petition seeks denial or revocation of a certification:

• Denial

• Revocation

4. Documentation to support the reasons outlined in the petition [Identify and attach all relevant documentation]:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

5. Petitioner is (check one):

☐ Individual ☐ Provider ☐ Provider of Air Ambulance Services ☐ Facility

☐ Plan/Issuer/FEHB Carrier

ATTESTATION:

By signing this attestation I certify that:

All of the information I provided after thorough research is true and complete to the best of my knowledge and I agree, if asked, to timely provide to the Departments any and all information on which I relied and that is reasonably available to me that will verify the accuracy and truthfulness of my completed attestation.

I understand that the Departments have the authority to verify information in this petition with other Federal or state agencies or other entities.

Petitioner’s Signature:

Print Name: Date:

Organization (if applicable): ____________________________________

Email address: Phone number: