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Control No. XXX-XXXX
Expiration
Date: XX/XX/XXXX
APPENDIX
5:
Federal
Certified Independent Dispute Resolution (IDR) Entity Reporting
Data
Elements
The
Departments of the Treasury, Labor, and Health and Human Services
(Departments) and the Office of Personnel Management (OPM) have
issued interim final rules establishing a Federal independent dispute
resolution process (Federal IDR process) that nonparticipating
providers or facilities, nonparticipating providers of air ambulance
services, and group health plans and health insurance issuers in the
group and individual market, or Federal Employees Health Benefits
(FEHB) carriers may use following the end of an unsuccessful open
negotiation period to determine the out-of-network rate for certain
services. More specifically, the Federal IDR process may be used to
determine the out-of-network rate for certain emergency services,
nonemergency items and services furnished by nonparticipating
providers at participating health care facilities, for air ambulance
services furnished by nonparticipating providers of air ambulance
services where an All-Payer Model Agreement or specified state law
does not apply. 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).
The
Departments must publish on a public website for each calendar
quarter in 2022 and subsequent years certain information regarding
the Federal IDR process. Therefore, under the interim final rules,
beginning January 1, 2022, the certified IDR entity must report
certain information to the Secretary each calendar month within 30
business days of the close of each month, in a format, manner, and
timeline specified by the Departments.
The
table below identifies data elements that certified IDR entities must
report to the Departments on a monthly basis. The Departments expect
that much of this information will be
collected by
the certified IDR entities during the normal course of the Federal
IDR process and will be captured as information submitted through the
Federal IDR portal. To the extent the necessary information is
captured directly through the portal, the Departments do not intend
for certified IDR entities to report duplicative information on a
monthly basis.
DATA
ELEMENT
|
DESCRIPTION
|
IDR
Entity Monthly Reporting Requirements
|
The
number of notices of IDR initiation (not including air ambulance
notices)
|
For
the immediately preceding month, the number of notices of IDR
initiation received by the certified IDR entity, not including
air ambulance notices.
|
Air
ambulance: the number of notices of IDR initiation
|
For
the immediately preceding month, the number of notices of IDR
initiation received by the certified IDR entity that pertain to
air ambulance services.
|
The
size of the provider practices and/or facilities
|
In
instances where the provider or facility submits the initial
Notice of IDR Initiation, specify whether each provider’s
practice subject to a dispute indicated fewer than 20 employees,
20 to 50 employees, 51 to 100 employees, 101 to 500 employees, or
more than 500 employees. For each facility subject to disputes,
indicate whether the facility has 50 or fewer employees, 51 to
100 employees, 101-500 employees, or more than 500 employees.
|
The
number of written notices of IDR initiation for which a final
determination was made (not including air ambulance notices)
|
For
the
immediately preceding month,
the number of written notices of IDR initiation for which a final
determination was made by the certified IDR entity.
|
Air
ambulance: the number of written notices of IDR initiation for
which a final determination was made
|
For
the
immediately preceding month,
the number of written notices of IDR initiation for which a final
determination was made under 26 CFR 54.9816-8T(c)(4)(ii), 29 CFR
2590.716-8(c)(4)(ii), and 45 CFR 149.510(c)(4)(ii) for air
ambulance services by the certified IDR entity.
|
Items
or services subject to determinations
|
For
the immediately preceding month, a description of each of the
items or services included in the notices of IDR initiation
received, including the relevant billing codes (such as Current
Procedural Terminology (CPT, Healthcare Common Procedure Coding
System (HCPCS), Diagnosis-Related Group (DRG), or National Drug
(NDC) Codes) furnished to the patient subject to dispute.
|
The
relevant geographic region
|
For
the immediately preceding month, the relevant
geographic region for purposes of the qualifying
payment amount (QPA) for the items and services
with respect to the notices of IDR initiation received.
|
The
offers submitted by each party
|
For
each determination issued during
the immediately preceding month,
the amount of the offers submitted by each party expressed as
both a dollar amount and as a percentage of the QPA, and whether
the offer selected was submitted by the plan, issuer, or FEHB
carrier, or provider or facility.
|
The
rationale for choosing the selected offer
|
For
each determination issued during
the immediately preceding month,
the rationale for the certified IDR entity’s selection of
offer, including the extent to which a decision relied on
criteria other than the QPA.
|
Additional
information on the parties involved
|
For
each determination issued during
the immediately preceding month, the
practice specialty and type of each provider or facility, as well
as identifying information for each plan, FEHB carrier, or
issuer, or provider or facility, such as each party’s name
and address, as applicable.
|
The
number of days elapsed between selection of the certified IDR
entity and the selection of the payment amount by the certified
IDR entity
|
For
each determination issued during
the immediately preceding month, the number of business
days taken between the selection of the certified IDR entity and
the selection of the payment amount by the certified IDR entity.
|
The
number of times during the month that the payment amount
determined exceeded the QPA specified by items or services
|
For
each determination issued during
the immediately preceding month, the
number of times the payment amount determined or agreed to was
higher than the QPA, as specified by items or services.
|
The
compensation paid to the certified IDR entity in settlement or
determination
|
The
total amount of compensation paid to the certified IDR entity
during the immediately preceding month, not taking into account
amounts refunded to the prevailing parties or administrative fees
collected.
|
Air
Ambulance: information about the air ambulance
|
For
the immediately preceding month, for each notice of IDR
initiation related to air ambulance services received:
1.
A description of each air ambulance service, including the
relevant billing and service codes;
2.
The point of pick-up (as defined in 42 CFR 414.605) for the
services included in such notification;
3.
The amount of the offer submitted under 26 CFR
54.9816-8T(c)(4)(i), 29 CFR 2590.716-8(c)(4)(i), and 45 CFR
149.510(c)(4)(i) (as applied by paragraph (b)(1) of 26 CFR
54.9817-2T, 29 CFR 2590.717-2, and 45 CFR 520) by the group
health plan, FEHB carrier, or health insurance issuer (as
applicable) and by the nonparticipating provider expressed as a
percentage of the QPA;
4.
Whether the offer selected by the certified IDR entity to be the
out-of-network rate was the offer submitted by the plan or issuer
(as applicable) or by the provider of air ambulance services;
5.
The extent to which the decision relied on the criteria in other
than the QPA;
6.
Air ambulance vehicle type, including the clinical capability
level of such vehicle (to the extent the parties have provided
such information);
7.
The identity for each plan, FEHB carrier, or issuer and provider
of air ambulance services, with respect to the notification; and
8.
For each determination, the number of days elapsed between
selection of the certified IDR entity and the selection of the
payment amount by the certified IDR entity.
|
Air
ambulance: compensation to certified IDR entity
|
For
the immediately preceding month, the total amount of compensation
paid to the certified IDR entity, not including amounts returned
to the prevailing parties or administrative fees collected.
|
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 1 hour 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.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Elizabeth Schumacher |
File Modified | 0000-00-00 |
File Created | 2024-07-19 |