APPENDIX 3 - Notice of Offer Data Elements FINAL CHANGE 2.23.23

OMB Control No. 1210-0169

Expiration Date: 11/30/2025

APPENDIX 3:
Federal Independent Dispute Resolution (IDR) Process Notice of Offer Data Elements

The Departments of the Treasury, Labor, and Health and Human Services (Departments) and the Office of Personnel Management (OPM) have issued 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, and 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 items and services. More specifically, the Federal IDR process may be used to determine the out-of-network rate for emergency services (in certain circumstances), certain nonemergency items and services furnished by nonparticipating providers at participating health care facilities, and 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 Public Health Service 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 table below identifies data elements that group health plans, health insurance issuers offering group and individual health insurance coverage, or FEHB carriers and out-of-network or nonparticipating health care providers, facilities, and providers of air ambulance services must submit not later than 10 days after the date of selection of a certified IDR entity.

DATA ELEMENT	DESCRIPTION
Offers of Payment from Each Party	Final offer of payment expressed as both a dollar amount and as a percentage of the corresponding Qualifying Payment Amount (QPA).
QPA for Applicable Year	QPA for the applicable year for the same or similar items or services. When batched items or services have different QPAs, the parties should provide these different QPAs and may provide different offers for these items and services, provided that the same offer should apply for all items and services with the same QPA.
The Size of the Provider Practice or Facility (applicable to providers and facilities)	Specify whether the provider practice or has fewer than 20 employees, 20 to 50 employees, 51 to 100 employees, 101 to 500 employees, or more than 500 employees. For facilities, the facility must specify whether the facility has 50 or fewer employees, 51 to 100 employees, 101 to 500 employees, or more than 500 employees.
Provider or Facility Practice Specialty (applicable to providers and facilities)	Specify the practice specialty of the provider or facility named in the dispute, such as anesthesiologist, plastic surgeon, etc.
Coverage Area (applicable to plans, issuers, and carriers)	Information on the coverage area of the plan, issuer, or carrier, the relevant geographic region for purposes of the QPA, and, for group health plans, whether the coverage is fully-insured or fully or partially self-insured (or for carriers, FEHB coverage).
Additional Required Information	Dispute reference number (provided through the Federal IDR portal), organization name, primary and secondary points of contact (including mailing address, phone numbers and email) and plan types. The parties should also provide any other information requested by the certified IDR entity related to the offer, as long as it does not relate to usual and customary charges, the billed amount, or payment or reimbursement rate for the items and services furnished by the provider or facility payable by a public payor.
Additional Optional Information for Items and Services that are not Air Ambulance Services	Additional information that the certified IDR entity must consider in making a payment determination: Information about the level of training, experience, and quality and outcome measurements (such as those endorsed by the consensus-based entity authorized under section 1890 of the Social Security Act) of the provider or facility that furnished the qualified IDR item or service. Information about the market share held by the nonparticipating provider or facility, or the plan (including, for self-insured plans, the market share of their third-party administrator (TPA) in instances where the self-insured plan relies on the TPA’s networks), issuer, or carrier in the geographic region in which the qualified IDR item or service was provided. Information about patient acuity or the complexity of furnishing the item or service to the participant, beneficiary, or enrollee. Information about the teaching status, case mix, and scope of services of the nonparticipating facility. Information about any demonstrations of good faith efforts (or lack thereof) made by the nonparticipating provider or nonparticipating facility or the plan, issuer, or carrier, as applicable, to enter into network agreements and, if applicable, contracted rates between the provider or facility and the plan, issuer, or carrier, as applicable during the previous 4 plan years. Any additional information submitted by either party that does not include information on usual and customary charges, the billed amount, or a payment or reimbursement rate for the items and services furnished by the provider or facility payable by a public payor.
Additional Optional Information for Air Ambulance Services	Additional information that the certified IDR entity must consider in making a payment determination: Information about the quality and outcomes measurements of the provider of air ambulance services that furnished the services. Information about the acuity of the condition of the participant, beneficiary, or enrollee receiving the services, or the complexity of providing the services to the participant, beneficiary, or enrollee. Information submitted by a party about whether the level of training, experience, and quality of medical personnel that furnished the air ambulance services. Information about the ambulance vehicle type, including the clinical capability level of the vehicle. Information about the population density of the point of pick-up (as defined in 42 CFR 414.605) for the air ambulance (such as urban, suburban, rural, or frontier). Information about any demonstrations of good faith efforts (or lack thereof) made by the nonparticipating provider of air ambulance services or the plan, issuer, or carrier, as applicable, to enter into network agreements and, if applicable, contracted rates between the provider or facility and the plan, issuer, or carrier, as applicable during the previous 4 plan years. Any additional information submitted by either party that does not include information on usual and customary charges, the billed amount, or a payment or reimbursement rate for the items and services furnished by the provider or facility payable by a public payor.

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 public reporting burden for this voluntary collection of information is estimated to be between 2.25 hours and 3 hours 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 1210-0169. Note: Please do not return the completed request for assistance to this address.

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