CMS defines a bundled payment as – …an arrangement under which a provider, facility, or provider of air ambulance services bills for multiple items or services under a single service code; or a plan makes an initial payment or notice of denial of payment to a provider, facility, or provider of air ambulance services under a single service code that represents multiple items or services (e.g., a DRG). Bundled payment arrangements are subject to the rules for batched determinations, but the certified IDR entity fee and administrative fee will be the same as for single determinations. (Federal Independent Dispute Resolution (IDR) Process Guidance for Certified IDR Entities (cms.gov))
FHAS reached out to CMS for further clarification to ensure providers had all necessary information to bundle properly – while adhering to CMS guidelines. They replied with the following clarification;
We are attaching bundling guidance [FHAS has linked this guidance as well] to address the scenario of bundled disputes for a single episode of care.
Please see the following guidance that is attached above to address whether a bundled dispute is related to a single episode of care.
In the first scenario, the certified IDR entity should confirm during the eligibility review whether a dispute submitted as a bundle satisfies the regulatory definitions of a bundled payment. To confirm whether either party billed or paid for the items and services using a single service code, certified IDR entities should review the supporting documentation submitted by both parties to the dispute and verify whether either:
- the claim form demonstrates that all items and services were billed using a single service code, or
- a payer-generated document (e.g., remittance, explanation of payment, explanation of benefits, etc.) demonstrates that all items and services were reimbursed using a single service code (for example, if a payer’s remittance lists multiple line-items but provides payment on only a single line-item listed in the remittance).
If the items and services were not billed or paid for using a single service code and therefore the dispute is not a valid bundle, the certified IDR entity should ask the initiating party to resubmit the dispute within four business days, in accordance with the August 2022 Technical Assistance on batching and bundling: https://www.cms.gov/files/document/TA-certified-independent-dispute-resolution-entities-August-2022.pdf.
There are no other updates at this time.
