The CAA added provisions applicable to group health plans and health insurance issuers in the group and individual markets in a new Part D of title XXVII of the Public Health Service Act (PHS Act) and also added new provisions to part 7 of the Employee Retirement Income Security Act (ERISA), and Subchapter B of chapter 100 of the Internal Revenue Code (Code). Section 102 of the No Surprises Act added Code section 9816, ERISA section 716, and PHS Act section 2799A-1, which contain limitations on cost sharing and requirements for initial payments for emergency services. Section 103 of the No Surprises Act amended Code section 9816, ERISA section 716, and PHS Act section 2799A-1 to establish a Federal independent dispute resolution (Federal IDR) process that nonparticipating providers or facilities and group health plans and health insurance issuers in the group and individual market may use following the end of an unsuccessful open negotiation period to determine the out-of-network rate for certain services. More specifically, the Federal IDR provisions 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, where an All-Payer Model Agreement or specified state law does not apply. Section 105 of the No Surprises Act created Code section 9817, ERISA section 717, and PHS Act section 2799A-2 which contain limitations on cost sharing and requirements for initial payments for air ambulance services, and allow plans and issuers and providers of air ambulance services to access the Federal IDR process. CAA provisions that apply to health care providers and facilities, and providers of air ambulance services, such as requirements around cost sharing, prohibitions on balance billing for certain items and services, and requirements related to disclosures about balance billing protections, were added to title XXVII of the PHS Act in a new part E.
The Department has updated the wage rates. The Departments have added the hour burden for the additional information to be shared with the initial payment or notice of denial of payment. The Department have also added the cost burden for the certified IDR entities to provide the payment determination notices to the parties. As a result, the hour burden has increased by 21,327 hours and the cost burden has increased by $10,420.
The changes to the forms described below are clarifying edits to the forms and instructions that do not impact the burden.
The Departments have made changes to the following forms: Notice of Offer (Data Elements) and Certified IDR Entity Written Determination.
(1) Notice of Offer:
-Revised the Additional Optional Information data element information so that it is consistent with the TMA v. U.S. Department of Health and Human Services (Case No. 6:21-cv-425 (E.D. Tex.)) and LifeNet, Inc. v. U.S. Department of Health and Human Services (Case No. 6:22-cv-162 (E.D. Tex.)) district court decisions and new regulatory language.
(2) Certified IDR Entity Written Determination:
-Added language regarding the weight given to the QPA and any additional credible information regarding the relevant factors, consistent with the TMA v. U.S. Department of Health and Human Services and LifeNet, Inc. v. U.S. Department of Health and Human Services district court decisions.
(3) Added language that if the certified IDR entity relies on additional information or additional circumstances in selecting an offer, its written decision must include an explanation of why the certified IDR entity concluded that this information was not already reflected in the QPA.
Federal IDR Process for Air Ambulance Services , Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities, IDR Entity Certification and IDR Entity Monthly Reporting, Request of Extension of Time Periods for Extenuating Circumstances
Requirements Related to No Surprise Billing Act, Part II (Independent Dispute Resolution Process) (CMS-10791)
Active
Federal IDR Process for Air Ambulance Services , Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities, IDR Entity Certification and IDR Entity Monthly Reporting, Request of Extension of Time Periods for Extenuating Circumstances
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Consolidated 1210-0169 Tri-dept PRA supporting statement 8.24.22 (clean).docx
Additional Information to Be Shared with the Initial Payment or Notice of Denial of Payment