IDR Entity Certification and IDR Entity Monthly Reporting

OMB Control Number: 0938-NEW

Expiration Date: XX/XXXX

APPENDIX 9

Standard Notice: Selected Dispute Resolution (SDR) Entity Notification to Health Care Providers and Facilities and Uninsured (or Self-Pay) Individuals

(For use by SDR Entities beginning January 1, 2022) Instructions

Under Section 2799B-7 of the Public Health Service Act, the U.S. Department of Health & Human Services (HHS) is required to establish a patient-provider dispute resolution process where an SDR entity can resolve a payment dispute between health care providers,¹ or health care facilities and individuals who are not enrolled in a group health plan or group or individual health insurance coverage, or a Federal health care program, or a Federal Employees Health Benefits (FEHB) program (uninsured individuals), or individuals who are enrolled but not seeking to file a claim with their group health plan or health insurance coverage, or FEHB health benefits plan (self-pay individuals) by determining the amount such individual s must pay their health care provider or facility. Under federal criteria, once HHS determines that an individual is eligible to dispute billed charges, HHS must select an SDR entity for the dispute resolution.

Once HHS assigns an SDR entity to a dispute, the SDR entity must inform both parties (the uninsured (or self-pay) individual and the health care provider or health care facility) of the selection.

Additionally, the SDR entity must request that the health care provider submit specific information within 10 business days of receipt of the notice so the SDR entity can use the data to make a determination on the dispute.

HHS has developed this standard notice so that providers or facilities and uninsured (or self-pay) individuals are informed of the SDR entity selection. To use this standard notice, the SDR entity, must fill in the blanks with the appropriate information.

NOTE: The information provided in these instructions is intended only to be a general informal summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or formal policy guidance upon which it is based. Readers should refer to the applicable statutes, regulations, and other interpretive materials for complete and current information, including the HHS interim final rules (IFR) titled Requirements Related to Surprise Billing; Part II, published on October 7, 2021.

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 1.3 hours per response, 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.

[Date]

Notice to Provider or Facility

and Uninsured (or Self-pay) Individual:

Selected Dispute Resolution Entity Selected by HHS

The U.S. Department of Health and Human Services (HHS) received a patient-provider dispute resolution initiation notice identifying you as parties in this matter. HHS has identified a selected dispute resolution (SDR) entity to review the case; your case Reference Number is [XXXX].

[SDR entity name] has been assigned to this case. They can be contacted at:

[SDR Entity Mailing Address]

[SDR Entity Phone #]

[SDR Entity Fax #]

[INCLUDE IF THE RECIPIENT OF THIS NOTICE IS THE PATIENT]

[UNINSURED (OR SELF-PAY) INDIVIDUAL NAME] does not need to take any action at this time.

[INCLUDE IF THE RECIPIENT OF THIS NOTICE IS THE PROVIDER OR FACILITY]

• Full Name of Patient

• Date Initiation Notice was received

• Last 4 digits of the Reference Number/Invoice Number/ Account Number on the bill the patient provided

• Items or services under dispute

Within 10 business days, [Health Care Provider / Facility Name] must send [SDR Entity Name] the following information. You are strongly encouraged to use the dispute resolution portal.

• A copy of the Good Faith Estimate provided to the patient for this case

• A copy of the bill sent to the patient for the items or services under dispute

• Justification for why the billed amount was appropriate and based on unforeseen circumstances that could not have reasonably been anticipated when the Good Faith Estimate was provided

[FOR BOTH UNINSURED (OR SELF-PAY) INDIVIDUAL AND PROVIDER OR FACILITY]

At any point after the dispute resolution process has been initiated but before the SDR entity makes a determination, the parties can settle on their own payment amount. In the event that the parties agree to settle on a payment amount, [health care provider / facility name] should notify the SDR entity through the dispute resolution portal, electronically, or in paper form, as soon as possible, but no later than 3 business days after the date of the agreement.

The settlement notification must contain the settlement amount, the date upon which settlement was reached, and documentation demonstrating that the provider or facility and uninsured (or self-pay) individual have agreed to the settlement. The settlement notice must also document that the provider or facility has applied a reduction to the uninsured (or self-pay) individual’s settlement amount that is equal to at least half the amount of the administrative fee. An example of a settlement notice can be found here [link to settlement notice]. You can also call 1-800-985-3059 to learn more about the settlement notice.

[SDR entity’s name] stated they have no conflicts of interest for this case, meaning they:

• Do not have a financial interest in this case and are not an employee of the health care provider, facility, or uninsured (or self-pay) individual.

• Did not have a familial, financial, or professional relationship with the health care provider, facility, or uninsured (or self-pay) individual within the last year.

• Do not have another conflict of interest with the health care provider, facility, or uninsured (or self-pay) individual.

If you have concerns about conflict of interest with this SDR entity, e-mail [email protected].

For more information, visit www.cms.gov/nosurprises/consumers

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.

1 For ease of reference, for purposes of this document, the term “provider” should be considered to include providers of air ambulance services.