CAA #15: Departments Issue Guidance Booklet for IDR Process

The Departments of Labor, Treasury, and Health and Human Services (Departments) have released a process guide for entities who may use the Independent Resolution Process (IDR), a process created as part of the Consolidated Appropriations Act (CAA) surprise billing legislation.

The Departments created the process guide to aid health plans, issuers, and FEHB carriers on how to apply requirements regarding recordkeeping, certification, and extension requests, among other items, to their business.

An excerpt from the booklet outlined below introduces the history of this regulation. Read our previous blogs summarizing the IDR Process:

Petition Instructions for IDR Process

IDR and External Review Process

Excerpt: IDR Background:

  • Effective January 1, 2022, the No Surprises Act (NSA) prohibits surprise billing in certain circumstances in which surprise billing is common. The NSA provides Federal protection for patients against surprise bills. In situations covered by the NSA, patients will be required to pay only the in-network cost-sharing amount for these services.
  • Health plans, issuers, and Federal Employees Health Benefits (FEHB) Program
    Carriers must pay the OON provider or facility or provider of air ambulance services an amount in accordance with a state All-Payer Model Agreement or specified state law, if applicable.
  • In the absence of an applicable All-Payer Model Agreement or specified state law,
    the plan must make an initial payment or a denial of payment within 30 calendar days, and the OON rate is the payment amount agreed upon between the payer and the plan.
  • If either party believes that the payment amount is not appropriate (it’s either too high or too low), they have 30 business days from the date of initial payment or denial of payment to notify the other party that they would like to negotiate.
  • Once notified, providers, facilities, or providers of air ambulance services, and health plans, may enter a 30-business-day open negotiation period to determine an alternate payment amount.
  • If that the open negotiation is unsuccessful, the NSA also provides for a Federal independent dispute resolution Process (Federal IDR Process) whereby a certified independent dispute resolution entity (IDR entity) will review the specifics of the case (or cases in the event of batched claims) and services received and determine the final payment amount.

Leave a Reply

Your email address will not be published. Required fields are marked *