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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.

HELPFUL HINT FOR NAVIGATING PRI IDRE

To facilitate efficient processing, stakeholders are encouraged to communicate your inquiries through our designated contact centers. PRI™ IDRE centers are based upon expertise. Your cooperation and attention to this streamlined process will yield in efficient handling of your inquiries.

 

When emails are sent to the incorrect address or submitted to multiple email boxes simultaneously your inquiry/RFI response is delayed due to the administration required to identify/confirm the appropriate recipient.

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PRI IDRE PAYMENT FAQS

Q: What do we do if the Notice of Offer (NOOF) and/or invoice is missing?

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A: Please send an email to PRI™’s Stakeholder Team at pri-idre@provider-resources.com. Please make sure to include the Dispute number and contact information should we need to follow up.

 

Q: What types of payment do you accept?

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A: PRI™ accepts payment by check or through our EZ Payment Portal. Payments by ACH or by Credit Card can be accepted through our EZ Payment Portal. PRI™ can also accept payments through your treasury management systems. Please contact our team for treasury management service payment arrangements. They can be reached by either email at pri-idrepayment@provider-resources.com or through our contact center at 855-479-4025 Option 1.

 

Q: Where do I send a payment by check?

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A: Checks can be mailed to our corporate address - Provider Resources, Inc.  Attn:  Accounting Department 153 East 13th Street, Suite 1400, Erie PA 16503.  This address can be used for priority mail / UPS / Fed Ex.

 

Q: How do I access your payment portal?

 

A: To access our payment portal, PRI Pay Now, please go to https://fnbezinvoice.billeriq.com/ebpp/PRI/Login/index. You can also find the link on the NSA IDRE page or our website https://www.provider-resources.com/idre. (Note: if you are not able to see the link when accessing the website, it may be due to browser security blockers).

 

Q: Do you accept payments by Credit Card?

 

A: Yes, PRI™ does accept payment by Credit Card through our EZ Payment Portal.

 

Q: How can I get a copy of your W-9 so I can set PRI™ up as a new vendor?

 

A: Please visit the NSA IDRE page of our website where you will find our 2024 W-9 available for download.  If you require additional information or forms be completed for new vendor set up, please email your request to pri-idrepayment@provider-resources.com.  We suggest that you allow pop-up blockers and clear cookies.

 

Q: I disagree with the invoice amount; who do I contact?   

 

A: Please send an email to pri-idre@provider-resources.com. Please make sure to include the Dispute number and contact information should we need to follow up.

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Q: Who do I contact if I disagree with the eligibility or payment decision?

 

A: Please send an email to pri-idre@provider-resources.com. Please make sure to include the Dispute number and contact information should we need to follow up.

PRI IDRE FAQS

Q: When should an objection be submitted if the non-initiating party believes that the Federal IDRE Process is not applicable?

 

A: For an objection to be considered, the information must  be provided no later than 1 business day after the end of the 3-business-day period for certified IDR entity selection.  If the objection is not submitted prior to the eligibility determination it will not be consider at a later date.  Additional information is available in the Federal Independent Dispute Resolution (IDRE) Process guidance for Certified IDR Entities (December 2023 Update to March 2023 Guidance) located at: https://www.cms.gov/nosurprises/help-resolve-payment-disputes/tips-for-disputing-parties

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Q: What documents should be submitted when initiating a dispute to facilitate IDRE review?

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A: CMS has provided specific guidance and resources for initiating parties entitled: “Helpful tips and tools for initiating an IDR dispute” which includes links to common mistakes, communications, submitting a complete dispute initiation, submitting fees and getting help.  

 

The information is found here:

https://www.cms.gov/nosurprises/help-resolve-payment-disputes/tips-for-disputing-parties

 

Based on CMS guidance, PRI™ recommends that the initiating party accurately complete the details tab in the IDRE portal, including:

  • Correct and complete contact information for the non-initiating party.

  • The claim number of the items or services for which you’re disputing payment.

  • A complete Explanation of Benefits (EOB).

  • The QPA for the items or services being disputed.

 

PRI™ also recommends that the initiating party submit:

  • Complete copy of remittance or notice of denial of payment for the disputed item or service, with appropriate codes.

  • Documentation, such as copies of emails sent to the non-initiating party, to demonstrate initiation of the required 30-business-day open negotiation period.

  • An email from a certified IDR entity requesting that a previously submitted dispute be resubmitted with corrections to batching errors (if applicable).

  • An email that can serve as evidence of an extension being granted (if applicable).

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The Tri-Departments also publish the Notice of Independent Dispute Resolution (IDR) Initiation Web Form User Guide (May 2024) which may be accessed at the following link: https://www.cms.gov/files/document/idr-notice-initiation-job-aid.pdf

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Q: Is there guidance for submitting bundled disputes?

 

A: As defined by the Tri-Departments, a bundled payment means an arrangement under which a provider, facility, or provider of air ambulance services bills for multiple items or services under a single service code; or a plan or issuer makes an initial payment or notice of denial of payment to a provider, facility, or provider of air ambulance services under a single service code that represents multiple items or services, e.g., a DRG.

 

Federal regulations regarding bundling arrangements are as follows: In the case of qualified IDR items and services billed by a provider, facility, or provider of air ambulance services as part of a bundled payment arrangement, or where a plan makes or denies an initial payment as a bundled payment, the qualified IDR items and services may be submitted as part of one payment determination. Bundled payment arrangements submitted under this paragraph (c)(3)(ii) are subject to the rules for batched determinations set forth in paragraph (c)(3)(i) of this section and the certified IDR entity fee for single determinations as set forth in paragraph (e)(2)(vii) of this section.

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Q: What documents should be submitted in support of the Offer?

 

A: Along with the Offer letter, PRI™ recommends that each party submit the following documentation in support of their Offer:

  • A screenshot from any third-party data aggregator website which includes national in-network rates for the same item or service, same provider specialty, in the same geographic region as the item or service at issue in the dispute.Each of the above data elements must be shown on the screenshot.

  • Copies of relevant plan documents.

  • Copies of the signature page of any previous in-network agreement between the parties.

  • Any records evidencing treatment details relevant to the Offer that do not contain Protected Health Information (PHI) or Personally Identifiable Information (PII).

  • Any other documents that support assertions made in the Offer letter.

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Q: Who do I contact to find out about the status of my dispute?

 

A: Please send an email to pri-idre@provider-resources.com. Please make sure to include the Dispute number and contact information should we need to follow up.

 

Q: What is the best way to contact PRI™ by email?

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A: For efficiency, please utilize the appropriate email address, as referenced below, based upon the subject of your inquiry/response. When emails are sent to the incorrect address or submitted to multiple email boxes simultaneously your inquiry/RFI response is delayed due to the administration required to identify/confirm the appropriate recipient.

 

Q: Where can I find information about the No Surprises Act and the Federal Independent Dispute Resolution process?

 

A: The Tri-Departments offer useful information on their websites such as but not limited to the following resources:

 

Overview of rules & fact sheets: https://www.cms.gov/nosurprises/policies-and-resources/overview-of-rules-fact-sheets

 

Federal Independent Dispute Resolution (IDR) Process Guidance for Disputing Parties: https://www.cms.gov/files/document/federal-independent-dispute-resolution-guidance-disputing-parties.pdf [December 2023 Update to October 2022 Guidance]

 

Notice of Independent Dispute Resolution (IDR) Initiation Web Form User Guide May 2024: https://www.cms.gov/files/document/idr-notice-initiation-job-aid.pdf

 

Certified Independent Dispute Resolution (IDR) Entity Selection Form Job Aid December 2023: https://www.cms.gov/files/document/certified-idr-entity-selection-form-job-aid.pdf

 

Independent Dispute Resolution (IDR) Notice of Offer Web Form Job Aid December 2023: https://www.cms.gov/files/document/independent-dispute-resolution-idr-notice-offer-web-form-job-aid-pdf.pdf-0

 

Notice of Independent Dispute Resolution (IDR) Initiation – Resubmission Web Form User Guide April 2024: https://www.cms.gov/files/document/idr-resubmission-user-guide.pdf

BATCHING GUIDELINES

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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.

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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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