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NO SURPRISES ACT – IDRE

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The Department of Health and Human Services, the Department of Labor, and the Department of the Treasury has certified Provider Resources, Inc. (PRI) as an independent dispute resolution entity (IDRE) in the federal independent dispute resolution process between providers, facilities or providers of air ambulance services and health plans.  

 

Effective January 1, 2022, if a provider or facility and a health plan cannot agree on the payment amount for an out-of-network item or service covered by the No Surprises Act, as a certified IDR entity (IDRE APP 141), PRI can be selected to determine the payment amount. PRI has served the government with similar initiatives as a trusted, fair, and balanced federal partner since 2008.

 

For any questions regarding the No Surprises Act or for more information regarding any of its provisions, including the Federal IDR process, visit https://www.cms.gov/nosurprises.

BATCHING GUIDELINES

REQUEST FOR INFORMATION

CONTACT THE IDRE TEAM

BATCHING GUIDELINES

Prior to August 3, 2023, batched cases were required to meet all of the following criteria:

 

  • The qualified IDR items or services were the same or similar items or services meaning they were items or services billed under the same service code, or a comparable code under a different procedural code system; and

  • The qualified IDR items or services were billed by the same provider, group of providers, facility, or provider of air ambulance services under the same NPI or Taxpayer Identification Number (TIN);

  • The payment (or notice of denial of payment) was made by the same group health plan, health insurance issuer or FEHB carrier;

  • The qualified IDR items or services were furnished within the same 30 business day period included a 30-business day open negotiation period that ended within 4 business days of IDR initiation (or are items or services for which the open negotiation period expired during the same 90-calendar day cooling off period)

 

Subsequent to the decision in the Texas Medical Association (TMA IV) lawsuit (i.e., on or after August 3, 2023), the following three (3) requirements remained applicable and should continue to be used to evaluate the appropriateness of batched items and services:

 

  • The qualified IDR items and services are billed by the same provider, group of providers, facility, or provider of air ambulance services;

  • Payment for the items and services are made by the same group health plan or health insurance issuer;

  • All the qualified IDR items and services are furnished included a 30-business day open negotiation period that ended within 4 business days of IDR initiation (or are items or services for which the open negotiation period expired during the same 90-calendar day cooling off period)

 

However, the requirements contained in the first bullet are no longer applicable. Whether an item or service submitted as part of a batched dispute meets the statutory and remaining regulatory standards for a batched dispute should be determined by the certified IDRE.

 

As a result of the TMA IV and TMA III opinions and orders, Code section 9816(c)(3)(A)(iii), ERISA section 716(c)(3)(A)(iii), and PHS Act section 2799A–1(c)(3)(A)(iii), in conjunction with the remaining non-vacated regulations, provide the effective standard for determining whether qualified IDR items and services may appropriately be batched together. That statutory text provides that items and services may be considered jointly as part of a single determination only if they are “related to the treatment of a similar condition. Therefore, until the Departments and OPM engage in notice and comment rulemaking on the circumstances under which items and services will be considered “related to the treatment of a similar condition,” disputes eligible for initiation of the Federal IDR process on or after August 3, 2023, should be submitted in a manner that is consistent with the statutes and regulations that remain in effect after the TMA IV and TMA III vacaturs. The District Court’s order in TMA IV does not impact the batching provisions set forth at 26 CFR 54.9816-8T(c)(3)(i)(A), (B), or (D), 29 CFR 2590.716- 8(c)(3)(i)(A), (B), or (D), and 45 CFR 149.510(c)(3)(i)(A), (B), or (D) and those provisions remain in effect. Certified IDR entities have the sole responsibility for determining whether the items and services submitted as part of a batched dispute meet the statutory and remaining regulatory standards for a batched dispute.”

 

In accordance with the statutory and remaining regulatory standards for a batched dispute, PRI batching guidance to identify Items and Services Related to the Treatment of a Similar Condition are defined as follows:

 

Qualified items and services may be batched as a similar condition:

  • When they were furnished to a single patient during the same patient encounter;

  • When they were furnished to one or more patients during different patient encounters and were billed under the same service code or a comparable code system (e.g., CPT, HCPCS, DRG);

  • For anesthesiology, radiology, pathology and laboratory, qualified IDR items and services would be considered to relate to the treatment of a similar condition when they are furnished under service codes belonging to the same Category I CPT code ranges.

 

Charts showing the Category I CPT code ranges are below.

PRI assessment of batched disputes will remain in effect until the completion of notice and comment rule making and/or until further guidance is published by the Tri-Departments.

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REQUEST FOR INFORMATION

Thank you for visiting our NSA IDRE page. Should you require clarification or guidance regarding the process of disputing claims, our team stands ready to offer comprehensive assistance. Whether you have questions about customer service or payment matters, please follow the email addresses that best support you. For additional information, please contact pri-idre-rfi@provider-resources.com. Any other assistance, please follow the email addresses below and contact our IDRE Team directly.

CONTACT THE IDRE TEAM

For any questions regarding IDRE Disputes, please fill out the form or email us at pri-idre@provider-resources.com.

For questions or concerns regarding administrative and IDRE Fee transactions, please email our accounting team at: pri-idrepayment@provider-resources.com.

PRI's leadership looks forward to serving you by providing the fair and balanced decisions you deserve.

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