Payment disputes between providers and health plans

Notice The Federal Independent Dispute Resolution (IDR) system is live. Due to a pause in the launch required to address a court ruling (see February 28 guidance (PDF)), there may be a backlog of Federal IDR requests and high initial case volume. This could cause delays in Federal IDR request processing. In response, the Departments will: Grant requests for extensions submitted by the parties or certified IDR entities, as appropriate. Monitor the volume and provide additional guidance, including updates to the timeframes under the Federal IDR process, as necessary. Updates will be announced here, and parties with disputes in process will be notified directly in advance of an update taking effect.

 

The “No Surprises” rules create new protections against out-of-network balance billing and establish a new process, called independent dispute resolution, which providers (including air ambulance providers), facilities, and health plans can use to resolve payment disputes for certain out-of-network charges.  As of January 2022, providers, facilities, and health plans can use this process to determine the payment rates for those services.

When a provider or facility gets a payment denial notice or an initial payment from a health plan for certain out-of-network services, the health plan, provider, or facility must start an open negotiation period that lasts 30 business days. At the end of the negotiation period, if the health plan and provider or facility haven’t agreed on a payment amount, either party can begin the independent dispute resolution process. 

The independent dispute resolution process:

• Brings in a third-party, known as a certified independent dispute resolution entity, to decide the payment amount. The parties have an opportunity to select the independent dispute resolution entity from a list of certified organizations, and everyone involved must attest to having no conflicts of interest.
• Requires the provider or facility and the health plan submit payment offers to the dispute resolution entity and additional information supporting their payment offers.
• Requires the dispute resolution entity to select from the disputing parties’ payment offers. Both the provider or facility and the health plan must abide by the entity’s decision and payment must be made within 30 calendar days.

Note: A dispute can’t be started until the required 30-business-day open negotiation period has ended, and must be started within 4 business days after the open negotiation period has ended, except in the circumstance described in this memorandum. (PDF) 

Start A Dispute

Have the following information ready: 

• Information to identify the qualified independent dispute resolution (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
• Your preferred certified IDR entity. See a list of certified independent resolution entities. 

Need help? Try this job aid (PDF) or view other resources on the IDR process.

If the parties agree on a rate after a dispute is started 
Disputing parties can continue to negotiate until the IDR entity makes a determination. If the parties agree on an out-of-network rate for a qualified IDR item or service after providing notice to the Departments of initiation of the Federal IDR process, but before the certified IDR entity has made its decision, the initiating party must notify the Departments. This notification must be sent no later than 3 business days after the date of the agreement. The initiating party should email the certified IDR entity and the Departments (at [email protected]) and attach a document that contains the following:

1. The agreed-upon out-of-network rate for the qualified IDR item, 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 (i.e., if parties choose not to evenly split the fee); and
3. Signatures from authorized signatories for both the initiating and the non-initiating party.

This information must be submitted within 3 business days of the agreement.

Deadlines under extenuating circumstances 
If the disputing parties experience extenuating circumstances during the IDR process that prohibit them from complying with deadlines to submit information, they may email the Departments (at [email protected]) and include the IDR dispute reference number, if known, to receive a Request for Extension Due to Extenuating Circumstances form and instructions for next steps. 

Get more information about the independent dispute resolution process, including guidance, FAQs, and model notices.  

Note: Not all items and services are subject to the independent dispute resolution process. For example, some states have their own processes to set prices for items and services or other laws that determine out-of-network payment amounts. 

If you have questions about the independent dispute resolution process or would like to report a potential violation of the process, contact the No Surprises Help Desk at 1-800-985-3059 from 8 a.m. to 8 p.m. EST, 7 days a week.

Timelines for dispute resolution processes are counted in business days, defined as 8 a.m. to 5 p.m. Monday through Friday, excluding federal holidays.