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IDR POLICY

FHAS Bundling Policy

Background

In discussions with the Centers for Medicare and Medicaid Services (CMS), initiating parties, and non-initiating parties, all parties have discussed a lack of clarity involving bundled disputes, i.e., different interpretations regarding which item(s) and/or service(s) are included for reimbursement in a bundled payment. CMS has indicated to FHAS that we can communicate with issuers to resolve the issue.

Purpose of this Policy

To clarify this matter, FHAS requests issuers to furnish FHAS with a statement outlining its bundling methodology. Please have an authorized representative for the issuer designate one (1) of the two (2) bundling statements below.

 

Option 1: When [Insert Issuer’s Name] has an allowed amount allocated to only one item or service, the allowed amount is only meant to be applied to that one item or service and should not be applied to other items and/ or services listed on the claim.

 

Implications:

  • If the statement above is submitted to FHAS, it would disallow any provider from submitting a single claim that contains only one item or service with an allowed amount greater than $0 to be disputed in the Federal IDR process as a bundled dispute for the entire claim amount.

  • This would require providers to submit multiple single disputes containing only one item or service for all item(s) and/ or service(s) that the provider wishes to dispute.

  • Please note that this would not disallow providers from submitting a single claim under the Federal IDR process as a batched dispute.

 

Option 2: When [Insert Issuer’s Name] has an allowed amount allocated to only one item or service, the allowed amount is meant to be applied to all item(s) and/ or service(s), regardless of the EOB stating $0 allowed for any given item or service on the claim.

 

Implications:

  • If the statement above is submitted to FHAS, it would allow any provider to submit a single claim that contains only one item or service with an allowed amount greater than $0 to be disputed in the Federal IDR process as a bundled dispute for the entire claim amount.

  • This would require providers to submit only one bundled dispute containing all items and/ or services for all item(s) and/ or service(s) on a single claim.

 

FHAS requests that a statement be provided to us indicating which option best describes your billing practices. Statements can be emailed to IDRE@fhas.com with the Subject “Bundling Policy Response”. Until a statement is received, FHAS, as directed by CMS, will process the dispute under the interpretation that the allowed amount is meant to be applied to all item(s) and/ or service(s), regardless of the EOB stating $0 allowed for any given item or service on the claim.

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