CMS Webpage Addresses Arbitrator Certification Under Surprise Medical Billing Rules | Practical Law

CMS Webpage Addresses Arbitrator Certification Under Surprise Medical Billing Rules | Practical Law

The Centers for Medicare and Medicaid Services (CMS) has established a webpage where the general public, health plans and insurers, health providers, providers of air ambulance services, and state regulators may submit a petition to deny an entity's application to become a certified independent dispute resolution entity (CIDRE) under the No Surprises Act (part of the Consolidated Appropriations Act, 2021 (CAA-21)).

CMS Webpage Addresses Arbitrator Certification Under Surprise Medical Billing Rules

Practical Law Legal Update w-033-4114 (Approx. 4 pages)

CMS Webpage Addresses Arbitrator Certification Under Surprise Medical Billing Rules

by Practical Law Employee Benefits & Executive Compensation
Published on 29 Nov 2021USA (National/Federal)
The Centers for Medicare and Medicaid Services (CMS) has established a webpage where the general public, health plans and insurers, health providers, providers of air ambulance services, and state regulators may submit a petition to deny an entity's application to become a certified independent dispute resolution entity (CIDRE) under the No Surprises Act (part of the Consolidated Appropriations Act, 2021 (CAA-21)).
The Centers for Medicare and Medicaid Services (CMS) has established a webpage where the general public, health plans and insurers, health providers, providers of air ambulance services, and state regulators may submit a petition to deny an entity's application to become a certified independent dispute resolution entity (CIDRE) under the No Surprises Act (part of the Consolidated Appropriations Act, 2021 (CAA-21)) (see Legal Update, Year-End COVID-19 Stimulus Legislation Includes Numerous Employee Benefit and Executive Compensation Provisions, Including Surprise Medical Billing Requirements for Health Plans and Practice Note, Surprise Medical Billing for Group Health Plans: Independent Dispute Resolution (IDR) Process).

Arbitrators Will Determine Payment Amounts

The No Surprises Act requires employer-sponsored group health plans and health insurers (in both the group and individual health insurance markets) to adopt protections against balance billing and out-of-network (OON) cost-sharing regarding:
  • Emergency services.
  • Non-emergency services delivered by non-participating (OON) providers at certain participating (in-network) health care facilities.
  • Air ambulance services furnished by OON providers of these services.
If a plan and provider disagree regarding the payment amount for certain OON charges and cannot resolve the matter using an open negotiations process, they may invoke an independent dispute resolution (IDR) process to do so. Under the IDR process, an arbitrator (the CIDRE) will make a binding determination regarding the payment amount. Specific timing rules govern the open negotiations and IDR procedures.
The No Surprises Act and its implementing regulations also include requirements for certifying IDR entities. To become a CIDRE, IDR entities must provide written documentation showing that they meet the eligibility criteria listed in the implementing regulations. Certain entities (for example, the public, health plans and insurers, health providers, and providers of air ambulance services) may petition to deny or revoke an IDR entity's certification.
For more information on the No Surprises Act's IDR procedures, see:

Petition for Denying CIDRE Certification

The CMS webpage includes a weekly list of CIDRE applicants. Each applicant will be posted for five business days, during which time the general public, health plans and insurers, health providers, providers of air ambulance services, and state regulators may submit a petition for denial of their application using the online form on the webpage. The form requires the following information:
  • The identity of the applicant at issue.
  • The reasons for the petition.
If a petition demonstrates that the applicant has failed to meet the No Surprises Act's requirements (see Practice Note, Surprise Medical Billing for Group Health Plans: Independent Dispute Resolution (IDR) Process: Certifying and Selecting IDR Decisionmakers), the applicant will be notified and given an opportunity to respond.