Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities

No Surprise Act: IDR Process

6. Appendix-HHS Vendor Management (VM) Data Elements

Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities

OMB: 1210-0169

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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

  1. Main Company Contact: First Name

  2. Main Company Contact: Last Name

  3. Main Contact: E-mail

  4. Main Company Contact: Phone Number

  5. Main Contact: Phone Ext (Yes/No)

  6. Main Company Contact: Phone Ext

  7. CEO: First Name

  8. CEO: Last Name

  9. CEO: E-mail

  10. CEO: Phone Number

  11. CEO: Phone Ext (Yes/No)

  12. CEO: Phone Ext

  13. CFO: First Name

  14. CFO: Last Name

  15. CFO: E-mail

  16. CFO: Phone Number

  17. CFO: Phone Ext (Yes/No)

  18. CFO: Phone Number Ext

  19. Billing and Payment Contact: First Name

  20. Billing and Payment Contact: Last Name

  21. Billing and Payment Contact: Phone Number

  22. Billing and Payment Contact: Phone Ext (Yes/No)

  23. Billing and Payment Contact: Phone Number Ext

  24. 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.

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