The most important factor impacting an Independent Dispute Resolution (IDR) entity’s determination is the accuracy and completeness of each party’s documentation.
An arbitrator considers only the information provided in each dispute and cannot independently investigate a claim — meaning, the information each party provides and the QPA is the only information considered in their review.
While providers and health plans should ensure they include comprehensive documentation, only pertinent documentation should be included, narrowing it down to only what is clearly relevant to the specific case. Burying the arbitrator in irrelevant information only makes it difficult to sift out the pertinent details.
It’s also important to note that an arbitrator must select an offer submitted by either the initiating party or the non-initiating party. Certified IDR entities do not have the authority to create a wholly unique payment amount to substitute in place of a submitted offer.
To properly initiate and support their case in an independent dispute resolution (IDR) under the No Surprises Act, the parties (provider or facility and the health plan) will typically need to provide the following documentation:
IDR Initiation Notice
This kicks off the formal IDR process after the 30-day open negotiation period. It must include information to identify the qualified IDR items or services including dates, locations, type, and an attestation that the items or services are eligible for the Federal IDR process. The initiation form must also include your preferred IDR entity.
Evidence of Good Faith Negotiation Attempt
The parties must show proof that they made a good faith attempt to negotiate and resolve the dispute. An Open Negotiation Period of 30 business days needs to be exhausted before IDR can begin. Each party has 4 business days following the end of the Open Negotiation Period to initiate the IDR process.
Copies of Relevant Plan Documents
Such as the insurance policy, provider contract, and plan terms/benefits explaining the coverage.
Proof of Payment/Remittance Advice
Documentation showing the initial payment made by the health plan and the amount in dispute.
Medical Records/Treatment Details
Clinical notes, operative reports, and any other records substantiating the items/services rendered to the patient.
Provider Credentials and Qualifications
Evidence that the provider was properly credentialed, board-certified, etc. for the services provided.
Previously contracted and/or negotiated rates
Contracted and/or negotiated rates information that parties are using to determine their appropriate payment positions.
Complicating Factors Documentation
Details on extenuating circumstances, complexity adjustments, etc. that may affect payment amounts.
State-Specific Documentation Requirements
Some states have issued their own guidance requiring additional documentation for IDRs involving their health plans/providers, such as whether certain self-insured plans are applicable to the state or federal IDRE process.
Notice of Offer Form
Both parties are expected to submit a Notice of Offer Form expressing their position on payment amount. It provides a final offer of an out-of-network rate and is submitted along with the supporting documentation listed above. Offers and other documentation are due no later than 10 business days after the entity determines the dispute to be eligible.
It’s important to note that some states have issued their own guidance requiring additional documentation for IDRs involving their health plans and providers, such as whether certain self-insured plans are applicable to the state or federal IDRE process.
By presenting a well-documented case, you increase your chances of a favorable determination.
If you are ever interested in understanding the reasoning behind the determinations reached or wish to review the opposing party’s documentation, you can request this information from our team at idre@fhas.com. We are here to assist you in navigating the IDR process and ensuring your submissions are as robust as possible.
The FHAS Difference
- Highly trained and experienced arbitrators with an average of 10+ years of expertise in arbitrating claims
- Diverse arbitration pool capable of handling surges in case volumes
- Rigorous Conflict of Interest Screening and Attestation Process to rule out any potential conflicts in arbitrating claims
- Industry Leaders in Healthcare claims adjudication
- Timely adjudications within the federally mandated timelines
- Over 100,000 payment determinations issued
See How to File for a detailed walkthrough of the process.
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As always, feel free to contact our team via chat, email IDRE@fhas.com, or call 800-664-7177, and our IDRE service team can answer your immediate questions.
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The information contained in this content piece is for general informational purposes only. While we strive to ensure the accuracy and completeness of the information presented, we make no representations or warranties of any kind, express or implied, about the accuracy, reliability, suitability, or availability with respect to the content or the information, products, services, or related graphics contained in the content piece for any purpose. Any reliance you place on such information is therefore strictly at your own risk. The content of this page is subject to change without notice. The information provided in this document does not constitute legal or other professional advice, and is non-binding upon FHAS and any federal government agencies.
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