Departments Issue Checklist for Surprise Billing IDR Process

This update was originally published by Larry Grudzien.

The Departments of IRS, DOL, and HHS (the “Departments”) recently issued a checklist of federal independent dispute resolution (IDR) and related requirements to help plan sponsors and insurers understand their obligations when processing claims for items and services that fall within the scope of the surprise medical billing protections of the No Surprises Act.

The Departments have received a number of questions and complaints regarding group health plan and  health insurance issuer requirements for making initial payments or sending notices of denial of  payment to nonparticipating providers, facilities, and providers of air ambulance services for items and  services for which the No Surprises Act balance billing protections apply.

Most questions and  complaints received to date by the No Surprises Help Desk relate to requirements to:

• Send an initial payment or notice of denial of payment within 30 calendar days after the provider or facility submits a bill or a claim;
• Provide the disclosures required with these initial payments or denials (such as the Qualifying Payment Amount (QPA), a contact telephone number, and email address); and
• Provide information about the 30-business-day open negotiation period.

For example, the Departments have received complaints that some plans and issuers are requiring providers and facilities to initiate the open negotiation period through a private issuer hosted web portal which may not allow for the submission of the standard open negotiation initiation notice to  initiate open negotiation as described under federal regulations.

This checklist is intended to help plans and issuers understand their obligations and comply with key requirements of the No Surprises Act when processing claims for items and services that fall within the scope of the new surprise billing protections for emergency services, non-emergency services performed by nonparticipating providers at participating health care facilities, and air ambulance services furnished by nonparticipating providers of air ambulance services(“qualified IDR item(s) or service(s)”).

Please note this is not an exhaustive list of No Surprises Act requirements.