Federal Independent Dispute Resolution (IDR) process

This guidance document is effective upon publication and is consistent with all relevant court cases and guidance for items and services furnished on or after October 25, 2022 for plan years (in the individual market, policy years) beginning on or after January 1, 2022 by an out-of-network provider subject to the Requirements Related to Surprise Billing; Part II, 86 FR 55980, and Requirements Related to Surprise Billing; Final Rule, 87 FR 52618.

This guidance document is effective upon publication and is consistent with all relevant court cases and guidance for items and services furnished on or after October 25, 2022 for plan years (in the individual market, policy years) beginning on or after January 1, 2022.

This guidance document is consistent with all relevant court cases and guidance as of the date of this publication and is applicable to items and services furnished before October 25, 2022 for plan years (in the individual market, policy years) beginning on or after January 1, 2022 by an out-of-network provider subject to the Requirements Related to Surprise Billing; Part II, 86 FR 55980.

The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.

This guidance amends the previous “Calendar Year 2023 Fee Guidance for the Federal Independent Dispute Resolution Process under the No Surprises Act” released on October 31, 2022 (prior 2023 guidance).

This guidance sets forth the administrative fee for participating in the Federal IDR process for calendar year 2023.

This guidance announces the administrative fee for participating in the Federal IDR process for calendar year 2022.

Data submitted by disputing parties and certified IDR entities to the Federal IDR portal.

The Departments of Health and Human Services (HHS), Labor, and the Treasury (the Departments) launched the federal Independent Dispute Resolution (IDR) portal on April 15, 2022.

The Departments are providing this partial report on 2022 Q4 (October 1 – December 31st, 2022) and a status update on the Federal IDR process after a full year of operations (from April 15, 2022 through March 31, 2023) in order to provide the public with up-to-date information.

The Departments published a status update on the Federal IDR process in August,5,6 included data on the Federal IDR process in the Calendar Year 2023 Fee Guidance, 7 and are publishing this initial, partial report representing the reporting period, April 15, 2022, through September 30, 2022 (i.e., two calendar quarters of Federal IDR process operations) today.

Due to a pause in the launch of the federal IDR portal to address a court ruling the federal IDR system first went live on April 15, 2022. There is no data to report for the first quarter of 2022.

This announcement serves as a notification to health care providers, emergency facilities, providers of air ambulance services, group health plans, health insurance issuers, Federal Employees Health Benefits (FEHB) Carriers (“Disputing Parties”), and certified IDR entities of steps the Departments are taking to conform to the court’s order.

The No Surprises Act (NSA) and its implementing regulations establish a Federal Independent Dispute Resolution (IDR) process that parties may use to determine the out-of-network rate for qualified IDR items or services after an unsuccessful open negotiation period.

Before accessing the Federal IDR process to determine the out-of-network rate for a qualified item or service, the disputing parties must engage in a 30-business-day open negotiation period to attempt to reach an agreement regarding the total out-of-network rate (including any cost sharing).

The Federal IDR process may be used to determine the out-of-network rate for certain emergency services, nonemergency items and services furnished by nonparticipating providers at participating health care facilities, and for air ambulance services furnished by nonparticipating providers of air ambulance services where an All-Payer Model Agreement or specified state law does not apply.

Applicants interested in becoming a certified independent dispute resolution (IDR) entity who meet the minimum qualification standards will proceed to the public petition period. During this period, the public can submit a petition for denial of the application for certification.

This document identifies data elements that an initiating party must provide in the notice, as well as information that the non-initiating party must provide in response to the initiating parties preferred certified IDR entity selection.

This document identifies data elements that an initiating party must provide if the parties to the Federal IDR process 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.

This document identifies data elements that group health plans, health insurance issuers offering group and individual health insurance coverage, or FEHB carriers and out-of-network or nonparticipating health care providers, facilities, and providers of air ambulance services must submit not later than 10 days after the date of selection of a certified IDR entity.

This document identifies data elements that a certified IDR entity must provide to the Departments in order to apply for certification.

This document identifies data elements that certified IDR entities must report to the Departments on a monthly basis.

An IDR entity must meet certain standards and be certified by the Departments in order to be selected for the Federal IDR process. The Departments have established a process to certify IDR entities, with certification being effective for a 5-year period.

Although the Federal IDR process provides for specific time periods which must be adhered to, a party may file for the time periods to be extended (excluding the timing of payment) in the case of extenuating circumstances at the Departments’ discretion on a case-by-case basis if the extension is necessary to address delays due to matters beyond the control of the parties or for good cause.

This document identifies data elements that certified IDR entities must include in the written decision.