Withdrawal Notice 10.23.23_clean

OMB Control No. 1210-0169

Expiration Date: XX/XX/XXXX

Appendix XX:

Federal Independent Dispute Resolution (IDR) Process: Withdrawal Request Notice 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 offering group of individual health insurance coverage, and Federal Employees Health Benefits (FEHB) Program carriers may use following the end of an unsuccessful open negotiation period to determine the out-of-network rate for certain items and services. More specifically, the Federal IDR process may be used to determine the out-of-network rate for emergency services furnished by nonparticipating providers or facilities, nonemergency items and services furnished by nonparticipating providers at participating health care facilities, and air ambulance services furnished by nonparticipating providers of air ambulance services where an All-Payer Model Agreement or specified state law does not apply.

Under the proposed rules, a dispute may be withdrawn from the Federal IDR process by the initiating party or certified IDR entity before a payment determination is made if one of the following conditions is met:

• The initiating party provides notification through the Federal IDR portal to the Departments and the certified IDR entity (if selected) that indicates that both parties agree to withdraw the dispute from the Federal IDR process without agreement on an out-of-network rate;

• The initiating party provides a standard Withdrawal Request Notice through the Federal IDR portal to the Departments, the certified IDR entity (if selected), and the non-initiating party of its request to withdraw the dispute from the Federal IDR process and the non-initiating party notifies the Departments, certified IDR entity (if selected), and initiating party through the Federal IDR portal of its agreement to withdraw from the Federal IDR process within 5 business days of the initiating party’s request. If the non-initiating party fails to respond within 5 business days of the initiating party’s request, the non-initiating party will be considered to have agreed to the withdrawal, and the dispute will be withdrawn;

• The certified IDR entity or the Departments cannot determine eligibility because both parties are unresponsive to any requests for additional information to determine eligibility; or

• The certified IDR entity cannot make a payment determination because both parties have failed to submit an offer.

The tables below identify data elements that would be required in the Withdrawal Request Notice that initiating parties would be required to use to notify the Departments, the certified IDR entity (if selected) and the non-initiating party of their request to withdraw a dispute from the Federal IDR process, and that non-initiating parties would be required to provide in order to respond to such request through the Federal IDR portal.

Data elements to request withdrawal (initiating party):

DATA ELEMENT	DESCRIPTION
Identification of the dispute	Dispute number assigned by the Federal IDR portal.
Withdrawal statement	A statement affirming that the initiating party requests to withdraw the dispute from the Federal IDR process.
Certified IDR entity fee (if applicable)	Allocation of how parties agree to pay certified IDR entity fee (if parties choose not to evenly split the fee).
Signature	Signatures from authorized signatories of the initiating party.

Data elements to respond to a withdrawal request(non-initiating party):

DATA ELEMENT	DESCRIPTION
Identification of the dispute	Dispute number assigned by the Federal IDR portal.
Withdrawal statement	A statement affirming that the non-initiating party agrees or disagrees to the initiating party’s request to withdraw the dispute from the Federal IDR process.
Certified IDR entity fee (if applicable)	Allocation of how parties agree to pay certified IDR entity fee (if parties choose not to evenly split the fee).
Signatures	Signature(s) from authorized signatories for the non-initiating party.

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 15-30 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 Research and Analysis, 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 1210-0169. Note: Please do not submit the data elements or notice described in this document to ebsa.opr@dol.gov. All Federal IDR process data elements and notices must be submitted through the Federal IDR portal at https://www.nsa-idr.cms.gov/.

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