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IDR Entity vs. CMS Responsibilities

By June 20, 2024July 12th, 2024No Comments

Under the No Surprises Act, the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury have certified 13 organizations to serve as Independent Dispute Resolution (IDR) entities in the Federal IDR process.

If a provider or facility and a health plan cannot agree on the payment amount for an out-of-network service covered by No Surprises Act rules, these organizations can be selected to make a payment determination.

While IDR entities have many responsibilities in this role, certain issues can only be addressed by action from Centers for Medicare & Medicaid Services (CMS). The charts below outline some of the roles during each step of the IDR process and clarifies your best contact for the most common questions or concerns.

Initiating the IDR Process

An IDR Entity MUST attest to being free of conflicts of interest, and MUST determine whether the Federal IDR Process applies to the items or services included in the dispute.

An IDR Entity will correct any clerical errors made by a party when submitting the Notice of Initiation. 

Only CMS can send the entity selection response forms. 

If there is a mistake in your dispute assignment, or you did not receive an entity selection response form, email FederalIDRQuestions@cms.hhs.gov

IDR Entities DO NOT have any access to these forms. 

IDR entities DO NOT make determinations of medical necessity, or review denials of coverage. 

Addressing the QPA

(The qualifying payment amount (QPA) is the basis for determining individual cost sharing for items and services covered by the balance-billing protections in the No Surprises Act (NSA), under certain circumstances.)

An IDR Entity CANNOT adjust the QPA if one party disagrees with the calculation of the QPA. 

ONLY CMS may determine whether the QPA has been calculated correctly by the plan.

If the certified IDR entity or a party believes that the QPA has not been calculated correctly, the certified IDR entity or party is encouraged to notify CMS through the Federal IDR portal or at FederalIDRQuestions@cms.hhs.gov, so that they may take action regarding the QPA’s calculation.

Documentation

The IDR Entity may provide copies of documentation such as EOB’s, Open Negotiations, or IDR Initiations to involved parties at their request. 

The IDR entity MUST provide the Notice of Offer (NOOF) form via a link, and send a corresponding invoice. Parties may receive an invoice a day later than their link, or vice versa.

Case Status

Entities CANNOT adjust disputes once they have been put in a closed status.

If an error was made on a determination, it is the IDR entity’s responsibility to request CMS reopen the dispute, and it is CMS’ responsibility to answer that request. 

An IDR Entity CAN withdraw disputes once they have been assigned. Reach out to the assigned entity and request the dispute be withdrawn. If you cannot get in contact with the entity, you may contact FederalIDRQuestions@cms.hhs.gov.

Parties to a dispute seeking an extension due to extenuating circumstances, MUST make the request to CMS. IDR entities DO NOT have the authority to grant extensions.

Question or Concern

Contact the IDR Entity

Contact CMS

Completing IDR Entity Selection

 

Clarification on the IDR timeline

 

Disputes regarding QPA calculations

 

Access to dispute documentation


(If documents are not provided
by opposing party)

 

Questions about fees and settlement payments

 

Requests to withdraw a dispute

Contact CMS if IDRE
does not respond. 

Asking for an extension

 

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