9. Tri-dept - monthly IDR entity reporting requirements (data elements) clean 9.28.21

DRAFT

OMB Control No. XXX-XXXX

Expiration Date: XX/XX/XXXX

APPENDIX 5:

Federal Certified Independent Dispute Resolution (IDR) Entity Reporting

Data Elements

The Departments of the Treasury, Labor, and Health and Human Services (Departments) and the Office of Personnel Management (OPM) have issued interim final rules establishing a Federal independent dispute resolution process (Federal IDR process) that nonparticipating providers or facilities, nonparticipating providers of air ambulance services, and group health plans and health insurance issuers in the group and individual market, or Federal Employees Health Benefits (FEHB) carriers 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 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, 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. Additionally, a party may not initiate the Federal IDR process if, with respect to an item or service, the party knows or reasonably should have known that the provider or facility provided notice and obtained consent from a participant, beneficiary, or enrollee to waive surprise billing protections consistent with PHS Act sections 2799B-1(a) and 2799B-2(a) and the implementing regulations at 45 CFR 149.410(b) and 149.420(c)-(i).

The Departments must publish on a public website for each calendar quarter in 2022 and subsequent years certain information regarding the Federal IDR process. Therefore, under the interim final rules, beginning January 1, 2022, the certified IDR entity must report certain information to the Secretary each calendar month within 30 business days of the close of each month, in a format, manner, and timeline specified by the Departments.

The table below identifies data elements that certified IDR entities must report to the Departments on a monthly basis. The Departments expect that much of this information will be collected by the certified IDR entities during the normal course of the Federal IDR process and will be captured as information submitted through the Federal IDR portal. To the extent the necessary information is captured directly through the portal, the Departments do not intend for certified IDR entities to report duplicative information on a monthly basis.

DATA ELEMENT	DESCRIPTION
IDR Entity Monthly Reporting Requirements
The number of notices of IDR initiation (not including air ambulance notices)	For the immediately preceding month, the number of notices of IDR initiation received by the certified IDR entity, not including air ambulance notices.
Air ambulance: the number of notices of IDR initiation	For the immediately preceding month, the number of notices of IDR initiation received by the certified IDR entity that pertain to air ambulance services.
The size of the provider practices and/or facilities	In instances where the provider or facility submits the initial Notice of IDR Initiation, specify whether each provider’s practice subject to a dispute indicated fewer than 20 employees, 20 to 50 employees, 51 to 100 employees, 101 to 500 employees, or more than 500 employees. For each facility subject to disputes, indicate whether the facility has 50 or fewer employees, 51 to 100 employees, 101-500 employees, or more than 500 employees.
The number of written notices of IDR initiation for which a final determination was made (not including air ambulance notices)	For the immediately preceding month, the number of written notices of IDR initiation for which a final determination was made by the certified IDR entity.
Air ambulance: the number of written notices of IDR initiation for which a final determination was made	For the immediately preceding month, the number of written notices of IDR initiation for which a final determination was made under 26 CFR 54.9816-8T(c)(4)(ii), 29 CFR 2590.716-8(c)(4)(ii), and 45 CFR 149.510(c)(4)(ii) for air ambulance services by the certified IDR entity.
Items or services subject to determinations	For the immediately preceding month, a description of each of the items or services included in the notices of IDR initiation received, including the relevant billing codes (such as Current Procedural Terminology (CPT, Healthcare Common Procedure Coding System (HCPCS), Diagnosis-Related Group (DRG), or National Drug (NDC) Codes) furnished to the patient subject to dispute.
The relevant geographic region	For the immediately preceding month, the relevant geographic region for purposes of the qualifying payment amount (QPA) for the items and services with respect to the notices of IDR initiation received.
The offers submitted by each party	For each determination issued during the immediately preceding month, the amount of the offers submitted by each party expressed as both a dollar amount and as a percentage of the QPA, and whether the offer selected was submitted by the plan, issuer, or FEHB carrier, or provider or facility.
The rationale for choosing the selected offer	For each determination issued during the immediately preceding month, the rationale for the certified IDR entity’s selection of offer, including the extent to which a decision relied on criteria other than the QPA.
Additional information on the parties involved	For each determination issued during the immediately preceding month, the practice specialty and type of each provider or facility, as well as identifying information for each plan, FEHB carrier, or issuer, or provider or facility, such as each party’s name and address, as applicable.
The number of days elapsed between selection of the certified IDR entity and the selection of the payment amount by the certified IDR entity	For each determination issued during the immediately preceding month, the number of business days taken between the selection of the certified IDR entity and the selection of the payment amount by the certified IDR entity.
The number of times during the month that the payment amount determined exceeded the QPA specified by items or services	For each determination issued during the immediately preceding month, the number of times the payment amount determined or agreed to was higher than the QPA, as specified by items or services.
The compensation paid to the certified IDR entity in settlement or determination	The total amount of compensation paid to the certified IDR entity during the immediately preceding month, not taking into account amounts refunded to the prevailing parties or administrative fees collected.
Air Ambulance: information about the air ambulance	For the immediately preceding month, for each notice of IDR initiation related to air ambulance services received: 1. A description of each air ambulance service, including the relevant billing and service codes; 2. The point of pick-up (as defined in 42 CFR 414.605) for the services included in such notification; 3. The amount of the offer submitted under 26 CFR 54.9816-8T(c)(4)(i), 29 CFR 2590.716-8(c)(4)(i), and 45 CFR 149.510(c)(4)(i) (as applied by paragraph (b)(1) of 26 CFR 54.9817-2T, 29 CFR 2590.717-2, and 45 CFR 520) by the group health plan, FEHB carrier, or health insurance issuer (as applicable) and by the nonparticipating provider expressed as a percentage of the QPA; 4. Whether the offer selected by the certified IDR entity to be the out-of-network rate was the offer submitted by the plan or issuer (as applicable) or by the provider of air ambulance services; 5. The extent to which the decision relied on the criteria in other than the QPA; 6. Air ambulance vehicle type, including the clinical capability level of such vehicle (to the extent the parties have provided such information); 7. The identity for each plan, FEHB carrier, or issuer and provider of air ambulance services, with respect to the notification; and 8. For each determination, the number of days elapsed between selection of the certified IDR entity and the selection of the payment amount by the certified IDR entity.
Air ambulance: compensation to certified IDR entity	For the immediately preceding month, the total amount of compensation paid to the certified IDR entity, not including amounts returned to the prevailing parties or administrative fees collected.

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Departments and OPM note that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this voluntary collection of information is estimated to be 1 hour and 15 minutes per response, including time for reviewing general information about requesting assistance, gathering information, completing and reviewing the collection of information, and uploading attachments if applicable. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Regulations and Interpretations, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number XXXX-XXXX. Note: Please do not return the completed request for assistance to this address.

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