CMS Opens Independent Dispute Resolution Process
Updated April 21, 2022

 

On Friday, April 15, 2022, the Centers for Medicare & Medicaid Services opened the Federal Independent Dispute Resolution (IDR) process for providers (including air ambulance providers), facilities, and health plans and issuers to resolve payment disputes for certain out-of-network charges.

To start a dispute, an initiating party will need:

  • Information to identify the qualified IDR items or services;
  • Dates and location of items or services;
  • Type of items or services such as emergency services and post-stabilization services;
  • Codes for corresponding service and place-of-service;
  • Attestation that items or services are within the scope of the Federal IDR process; and
  • The initiating party’s preferred certified IDR entity. A list of certified entities can be found here.


At the end of the 30-business-day open negotiation period, initiating parties have 4 business days to initiate a dispute via the portal. As a result of the recent decision in Texas Medical Ass’n, et al. v HHS, the Departments will give disputing parties whose open negotiation period expired before today, April 15, 2022, 15 business days to file an initiation notice via the IDR Portal.

Even after starting the Federal IDR process, disputing parties can continue to negotiate until the IDR entity makes a determination. If the parties reach an agreement on the out-of-network payment rate, they should email the certified IDR entity and the Departments (at federalIdrquestions@cms.hhs.gov).

If the disputing parties experience extenuating circumstances during the IDR process that prohibit them from complying with deadlines to submit information, they may email the Departments (at federalIdrquestions@cms.hhs.gov) to receive a Request for Extension Due to Extenuating Circumstances form and instructions for next steps.

To learn more about the independent dispute resolution process, including to read guidance materials, FAQs, and model notices, visit www.cms.gov/nosurprises.