IDR Process & Eligibility Guide

For Maximus to render a payment determination for a dispute, the dispute must follow specific eligibility guidelines set forth in the NSA.

The items or services in dispute must fall into the three main categories specified in the NSA to be eligible for the IDR process:

• Covered emergency services by an out-of-network provider/facility.
• Covered non-emergency services from an out-of-network provider delivered as part of a patient’s visit to an in-network facility.
• Covered services from out-of-network providers of air ambulance services.

Item/services in dispute must have been furnished after the NSA being enacted on January 1, 2022

Additionally, the IDR process requires certain timeframes, required steps, and specific guidelines for all items/services in dispute to be eligible for the IDR process:

• Open Negotiation: All parties must go through a 30-business-day open negotiation period prior to starting the Federal IDR process.
• Notice of IDR Initiation: The initiating party must submit the required forms to start the Federal IDR process within 4 business days after the end of the 30-business-day open negotiation period.
• Specified State Law or All-Payer Model Agreement: In some states, the Federal IDR process is surpassed by a Specified State Law or All-Payer Model Agreement that provides a method for determining the total OON amount payable. Learn more about determining the applicability of the Federal IDR Process here: Basic State - Territory IDR Deeming Chart
• Non-eligible circumstances: The NSA protections do not apply to the following:
  • Certain government programs such as Medicare, Medicaid, Indian Health Service, Veterans Affairs Health Care, and Tricare
  • Not covered items/services under the health plan
  • Ground ambulance services
  • Certain types of health plans, such as short-term plans, retiree-only plans, workers’ compensation plans, etc.

A bundled payment arrangement is an arrangement under which:

• A provider, facility, or provider of air ambulance services bills for multiple items or services furnished to a single patient under a single service code that represents multiple items or services (for example, a diagnostic related group (DRG) code); or
• A plan or issuer 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 furnished to a single patient (for example, a DRG code).

Disputes may be bundled by a single CPT, DRG, or HCPCS code.

Bundled payment arrangements are subject to the certified IDR entity fee and administrative fee for single determinations.

Initiating parties can batch multiple item or services under the same dispute as long as they meet the batching criteria. Batching items/services helps to decrease the number of IDR proceedings, avoids unnecessary complications from single disputes from plans and providers, and streamlines certified IDR entity decision-making.

Maximus current batching rules are in alignment with those as stated in 45 CFR 149.510(c)(3) and clarified in the Technical Assistance for Certified IDR Entities (August 2022). Maximus has implemented the following criteria for batching claims (all four must be met):

1. The qualified IDR items or services are billed by the same provider, group of providers, facility, or provider of air ambulance services, under the same National Provider Identifier (NPI) or Taxpayer Identification Number (TIN)
2. Payment (or notice of denial of payment) is made by the same group health plan, health insurance issuer, or Federal Employees Health Benefits (FEHB) carrier 
   1. For fully insured health plans, this means that qualified IDR items or services can be batched if payment is made by the same issuer, even if the qualified IDR items and services relate to claims from different fully insured group or individual health plan coverage offered by the issuer
   2. For self-insured group health plans, qualified IDR items or services can be batched only if payment is made by the same plan, even if the same third- party administrator (TPA) administers multiple self-insured plans
3. The qualified IDR items or services are the same or similar items or services 
   1. To be the “same or similar”, the qualifying IDR items or services must be billed under the same service code with modifiers, or billed under comparable codes with modifiers under a different procedural code system. A comparable code under a different procedural code system is a code that, along with any relevant modifiers, indicates an identical item or service
   2. Coding systems that could be used to describe a qualified IDR item or service, including the Current Procedural Terminology (CPT) Coding System, the Healthcare Common Procedure Coding System (HCPCS), and the Diagnosis-Related Group (DRG) Coding System
4. The qualified IDR items or services were furnished within the same 30-business-day period (or are items or services for which the open negotiation period expired during the same 90-calendar-day cooling-off period)

Please note, the revised definition of batched qualified IDR items or services as finalized in the Federal IDR Operations Final Rule (CMS-9897-F) will apply to disputes with open negotiation periods beginning on or after November 1, 2026:

1. The qualified IDR items and services are considered paid by the same plan or issuer when: 
   1. For fully insured group health plans and individual health insurance coverage, the same issuer is required to make payment for the qualified IDR items and services, even if the qualified IDR items and services relate to claims from different insured group health plans or individual market policies
   2. For self-insured group health plans, the same self-insured group health plan is required to make payment for the qualified IDR items and services, including when the plan makes payments through a TPA. Claims from multiple self-insured group plans using the same TPA may not be batched, as they are not considered paid by the same plan
2. The qualified IDR items and services are considered related to the treatment of a similar condition when: 
   1. They are furnished to a single patient, during the same patient encounter. A single patient encounter is defined as a single patient encounter on one or more consecutive days during which the qualified IDR items or services were furnished to the same patient and billed on the same claim form
   2. They are furnished to one or more patients and billed under the same service code or a comparable code under a different procedural code system, such as CPT codes with modifiers, if applicable, HCPCS with modifiers, if applicable, or DRG codes with modifiers, if applicable
   3. For anesthesiology, radiology, pathology, and laboratory qualified IDR items and services, they are furnished to one or more patients and were billed under service codes belonging to the same Category I CPT code ranges
3. Batched qualified IDR items and services must be furnished within the same 30-business-day period following the date on which the first item or service included in the batched determination was furnished and have been the subject of a 30-business-day open negotiation period that ended within 4 business days of IDR initiation (the cooling off period specifically for batched disputes will be reduced from 90 calendar days to 30 business days)

When providing narrative information and additional documentation to support your offer of payment in a dispute, keep in mind the following basic guidelines related to the contents of your submission:

Relevant and specific

Information provided should relate to your offer and be pertinent to the claim in dispute (as opposed to general information or documents that do not speak to the specifics of the case).

Pertains to the factors considered

In support of your offer, you may submit information regarding any of the circumstances or factors listed below, and any additional information that relates to the offer.

Additional Circumstances or Factors for Qualified Non-Air Ambulance Items and Services

1. The level of training, experience, and quality and outcomes measurements of the provider or facility that furnished the qualified IDR item or service (such as those endorsed by the consensus-based entity authorized in Section 1890 of the Social Security Act) of the provider or facility that furnished the qualified IDR item or service.
2. The market share held by the provider or facility, or that of the plan, in the geographic region in which the qualified IDR item or service was provided.
3. The acuity of the participant, beneficiary, or enrollee receiving the qualified IDR item or service, or the complexity of furnishing the qualified IDR item or service to the participant, beneficiary, or enrollee.
4. The teaching status, case mix, and scope of services of the facility that furnished the qualified IDR item or service, if applicable.
5. Demonstrations of good faith efforts (or lack thereof) made by the provider or facility or the plan to enter into network agreements with each other, and, if applicable, contracted rates between the provider or facility, as applicable, and the plan during the previous 4 plan years.
6. Disputing parties may provide additional information relevant to the submitted QPA.

Additional Circumstances/Factors for Qualified Air Ambulance Items or Services

1. The quality and outcomes measurements of the provider of air ambulance services that furnished the services.
2. The acuity of the condition of the participant, beneficiary, or enrollee receiving the services, or the complexity of providing services to the participant, beneficiary, or enrollee.
3. The level of training, experience, and quality of medical personnel that furnished the air ambulance services.
4. The air ambulance vehicle type, including the clinical capability level of such vehicle.
5. The population density of the point of pick-up for the air ambulance of the participant, beneficiary, or enrollee (such as urban, suburban, rural, or frontier).
6. Demonstrations of good faith efforts (or lack of thereof) made by the provider of air ambulance services or the plan to enter into network agreements, as well as contracted rates between the provider and the plan during the previous 4 plan years.
7. Disputing parties may provide additional information relevant to the submitted QPA.

Organized and concise

Structuring your narrative brief into sections for each referenced factor is helpful and enhances readability, as does keeping the information succinct and pertaining specifically to the claim in dispute.

In support of eligibility

• Proof of initiating open negotiation
  • If emailed, include the email or screenshot of email reflecting that the Open Negotiation Notice was sent to the non-initiating party
  • If mailed or sent by courier/delivery service, include documentation that confirms the recipient’s name, address, and the date the Open Negotiation Notice was sent to the non-initiating party
• Full explanation of benefits with arbitration language/instructions
• Proof of Independent Dispute Resolution initiation (including email or screenshot of email reflecting that the Notice of IDR initiation was sent to the non-initiating party)
• Member ID Card (if applicable)
• UB-04 Form (for bundled disputes)
• CMS extension documentation confirming extension approval