Federal IDR Process for Air Ambulance Services

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APPENDIX 6
Independent Dispute Resolution and Patient-Provider Dispute Resolution Processes; 
Vendor Management 
Data Elements
The Departments of the Treasury, Labor and Health and Human Services (collectively, the Departments) and the Office of Personnel Management have issued interim final rules establishing an independent dispute resolution (IDR) process that out-of-network or nonparticipating health care facilities and providers (including air ambulance providers) and group health plans and health insurance issuers of group and individual coverage may utilize following the end of an open negotiation period.  This IDR process is available only for certain services, such as out-of-network emergency services, certain out-of-network services at an in-network facility where sufficient notice and consent is not provided, or air ambulance services.  This IDR process is also only available if a state All-Payer Model Agreement or specified state law does not apply.  

Additionally, HHS has issued interim final rules (45 CFR 149.620) that provide protections for the uninsured by requiring the Secretary of HHS to establish a process (referred to as patient-provider dispute resolution) under which an uninsured (or self-pay) individual, with respect to an item or service, who received, from a health care provider or health care facility a good faith estimate of the expected charges for furnishing such item or service to such individual and who after being furnished such item or service by such health care provider or health care facility is billed by such health care provider or health care facility for such item or service for charges that are substantially in excess of such estimate, may seek a determination from a selected dispute resolution (SDR) entity for the charges to be paid by such individual to such health care provider or health care facility. 

As part of this process, HHS is responsible for the payment of the fee to the IDR Entity.  The table below identifies data elements that an IDR Entity will be required to provide to HHS so that the IDR Entity can pay the required administrative fee. 

Note that this PRA package is for HHS’ requirements at 45 CFR 149.620. 

Independent Dispute Resolution Entity Organization Data
    1. Legal Business Name
    2. Marketing Name (dba)
    3. Tax Identification Number (TIN)
    4. Unique Company Tracking ID
    5. Company Address: Address
    6. Company Address: Address 2
    7. Company Address: City
    8. Company Address: State
    9. Company Address: Zip Code
    10. Company Mailing Address: Address
    11. Company Mailing Address: Address 2
    12. Company Mailing Address: City
    13. Company Mailing Address: State
    14. Company Mailing Address: Zip
    15. Name of Holding Company

Contacts
    16. Main Company Contact: First Name
    17. Main Company Contact: Last Name
    18. Main Contact: E-mail
    19. Main Company Contact: Phone Number
    20. Main Contact: Phone Ext (Yes/No)
    21. Main Company Contact: Phone Ext
    22. CEO: First Name
    23. CEO: Last Name
    24. CEO: E-mail
    25. CEO: Phone Number
    26. CEO: Phone Ext (Yes/No)
    27. CEO: Phone Ext
    28. CFO: First Name
    29. CFO: Last Name
    30. CFO: E-mail
    31. CFO: Phone Number
    32. CFO: Phone Ext (Yes/No)
    33. CFO: Phone Number Ext
    34. Billing and Payment Contact: First Name
    35. Billing and Payment Contact: Last Name
    36. Billing and Payment Contact: Phone Number
    37. Billing and Payment Contact: Phone Ext (Yes/No)
    38. Billing and Payment Contact: Phone Number Ext
    39. Billing and Payment Contact: E-mail

Payment and User Fee Charges Operations Data Elements for Independent Dispute Resolution Entity
    1. Reason for Submission: New EFT Authorization (Y/N), Revision to Current Authorization (e.g. account or financial institution changes) (Y/N)
    2. Check here if EFT payment is being made to the Affiliate of the Entity (Attach letter authorizing EFT payments to the Affiliated Entity)
    3. Since your last EFT authorization agreement submission, have you had a Change of Ownership and/or Change of Address? (Y/N) If yes, submit a change of information prior to accompanying this EFT authorization.
    4. TIN
    5. Payee ID
    6. Legal Business Name – Legal entity name should be the same name provided to the Internal Revenue Service on Form W-9, Request for Taxpayer Identification Number (TIN) and Certification
    7. Marketing Name:
    8. Entity: Name (DBA)
    9. Entity: Name (Division)
    10. Entity: Address
    11. Entity: Address 2 – Optional demand letter routing information (e.g. Attention: Accounting Department)
    12. Entity: City
    13. Entity: State
    14. Entity: Zip Code
    15. Entity: Country
    16. IRS 1099: Address
    17. IRS 1099: Address 2
    18. IRS 1099: City
    19. IRS 1099: State
    20. IRS 1099: Zip Code
    21. IRS 1099: Country
    22. Letter from Financial Institution for Account Validation
    23. Financial Institution Routing Transit Number (ACH only)
    24. Entity Depositor Account Number
    25. Type of Account: Checking or Savings
    26. Payment Amount
    27. Invoice Number
    28. Invoice Date
    29. EFT Banking Information: Title (up to four instances)
    30. EFT Banking Information: First Name (up to four instances)
    31. EFT Banking Information: Last Name (up to four instances)
    32. EFT Banking Information: Phone Number (up to four instances)
    33. EFT Banking Information: Phone Number Ext (up to four instances)
    34. EFT Banking Information: E-mail (up to four instances)
    35. EFT Banking Information: Bank Name (up to four instances)
    36. EFT Banking Information: Address (up to four instances)
    37. EFT Banking Information: Address 2 (up to four instances)
    38. EFT Banking Information: City (up to four instances)
    39. EFT Banking Information: State (up to four instances)
    40. EFT Banking Information: Zip Code (up to four instances)
    41. EFT Banking Information: Country (up to four instances)
    42. Change of Ownership Date
    43. Business Line to which this banking information is applicable – Also referred to as “Business Line” or “Program Type” which includes IDRE User Fees.
    44. Financial Reporting IP Address
    45. Authorized/Delegated Official: Title
    46. Authorized/Delegated Official: First Name
    47. Authorized/Delegated Official: Last Name
    48. Authorized/Delegated Official: Phone Number
    49. Authorized/Delegated Official: Phone Ext (Yes/No)
    50. Authorized/Delegated Official: Phone Number Ext
    51. Authorized/Delegated Official: E-mail
    52. Authorized/Delegated Official: Signature
    53. Date of Authorization
    54. Payment Contact: First Name
    55. Payment Contact: Last Name
    56. Payment Contact: Phone Number
    57. Payment Contact: Phone Ext (Yes/No)
    58. Payment Contact: Phone Number Ext
    59. Payment Contact: E-mail
    60. Electronic Funds Transfer Authorization Agreement (check box)
    61. Effective Date for Financial Information
    62. Financial Authority Contact: Title
    63. Financial Authority Contact: First Name
    64. Financial Authority Contact: Last Name
    65. Financial Authority Contact: Phone Number
    66. Financial Authority Contact: Phone Ext (Yes/No)
    67. Financial Authority Contact: Phone Ext
    68. Financial Authority Contact: E-mail
    69. Financial Institution: Name
    70. Financial Institution: City
    71. Financial Institution: State
    72. Financial Institution: Zip
    73. Financial Institution Contact: First Name
    74. Financial Institution Contact: Last Name
    75. Financial Institution Contact: Phone Number
    76. Financial Institution Contact: Phone Ext (Yes/No)
    77. Financial Institution Contact: Phone Number Ext
    78. Payee Record: TIN
    79. Payee Record Contact: Title
    80. Payee Record Contact: First Name
    81. Payee Record Contact: Last Name
    82. Payee Record Contact: Phone Number
    83. Payee Record Contact: Phone Ext (Yes/No)
    84. Payee Record Contact: Phone Number Ext
    85. Payee Record Contact: Email
    86. Payee Record Contact: Address
    87. Payee Record Billing Address: Address
    88. Payee Record Billing Address: Attention
    89. Payee Record Billing Address: City
    90. Payee Record Billing Address: State
    91. Payee Record Billing Address: Zip Code
    92. Type of Corporate Entity

Pay.gov Fields
    1. Company Name
    2. Entity ID/Unique Company Tracking ID
    3. Invoice Number
    4. Program Type
    5. Address
    6. City
    7. State
    8. Zip
    9. Primary Contact Name
    10. Primary Contact Phone Number
    11. Primary Contact Email
    12. Secondary Contact Name
    13. Secondary Phone Number
    14. Secondary Contact Email
    15. Payment authorization attestation (check box)

Paperwork Reduction Act Statement 
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number.  The valid OMB control number for this information collection is 1210-0169.  The time required to complete this information collection is estimated to average of 1.5 hours per respondent, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. 


PRIVACY ACT STATEMENT:  CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to:  (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entity’s compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.