CMS Starts Independent Dispute Resolution Under No Surprises Act

On April 15, 2022, CMS opened the Federal Independent Dispute Resolution (IDR) process for providers, facilities, and health plans and issuers to resolve payment disputes for certain out-of-network charges.

After the end of a 30-business day open negotiation period, during which all parties act in good faith to try to reach an out-of-network payment agreement, a provider, facility, and health plan or issuer can use the online portal to initiate the Federal IDR process.

To start a dispute via the portal, which must be done within 4 business days after the 30-busines day negotiation period, an initiating party will need the following:

• Information to identify the qualified IDR items or services.
• Dates and location of items or services.
• Type of items or services, such as emergency services and post-stabilization services.
• Codes for corresponding service and place-of-service.
• Attestation that items or services are within the scope of the Federal IDR process.
• The initiating party’s preferred certified IDR entity (a list of certified entities can be found here).

Disputing parties can continue to negotiate until a determination through the IDR process. If an agreement is reached after the IDR process has been initiated, the parties should email the certified IDR entity and the Departments of Health and Human Services (HSS;  FederalIDRQuestions@cms.hhs.gov) with the following information within 3 business days of the agreement:

1. The agreed-upon out-of-network rate for the qualified IDR item, batched determinations, or service (that is, the total payment amount, including both participant, beneficiary, or enrollee cost sharing and the total plan or coverage payment, including amounts already paid).
2. Allocation of how parties agree to pay certified IDR entity fee (if parties choose not to evenly split the fee).
3. Signatures from authorized signatories for both the initiating and the non-initiating party.

In the event of extenuating circumstances that prevent the parties from complying with deadlines, the parties may email the Departments (FederalIDRQuestions@cms.hhs.gov) to receive a Request for Extension Due to Extenuating Circumstances form and instructions for next steps. To learn more about the Independent Dispute Resolution process, including to read guidance materials, FAQs, and model notices, visit www.cms.gov/nosurprises