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How to File an Independent Dispute Resolution

Independent Dispute Resolution (IDR) is utilized as a means for resolving payment disputes between healthcare providers and health plans, in line with the CMS No Surprises Act.  The goal of the IDR process is to provide an impartial decision on fair payment without involving the patient in the process or subjecting them to surprise medical bills for out-of-network services.

The IDR process involves the following steps:

STEP 1

Initiating a Dispute:

  • When initiating a dispute in the CMS Portal, the initiating party selects an IDRE from the dropdown menu (e.g. Select “Federal Hearings and Appeals Services”)
  • The non-initiating party can agree or disagree with the selected IDRE (such as “Federal Hearings and Appeals Services”)
  • If parties cannot agree on an IDRE within 3 days, an IDRE is randomly assigned by the Departments from the remaining eligible options.
  • If one party doesn’t respond, the opposing party’s selected IDRE is assigned.
 
 

STEP 2

IDRE Assignment Notification:

  • The CMS Portal sends an email to both parties notifying them of the assigned IDRE.
  • Once both parties receive an email regarding the assigned IDRE, the IDRE receives the dispute.
  

STEP 3

Objecting to Eligibility/Documentation:

  • Objections to eligibility should be submitted in the IDRE Selection Response Form; Objections should not be made after the selection of the IDRE.
  • If the eligibility documentation is not available when the IDRE is assigned the dispute, FHAS will request required eligibility documentation from the parties.
  • The Non-initiating parties must provide documentation supporting their eligibility objections
  • If FHAS has requested an offer and payment, but a party believes a dispute is ineligible, it is recommended to still submit payment and an offer while eligibility is determined to avoid default determinations.
  • FHAS can only make an eligibility decision based upon the parties’ submitted documentation.
  

STEP 4

Requests for Payment and Offer:

  • Once a dispute is determined eligible, FHAS will request payment via email (an email invoice).
  • Payments can be made via ACH, check, credit card.
  • Additionally, the federal IDR portal will send an email to the parties notifying them that an offer is due; the email will contain a link by which a party can submit an offer and supporting offer documents
  • Offer submission requests are sent on the same day as payment requests.
  

STEP 5

A Rendered Decision:

  • Once the timeline to submit payment and offer has ended, FHAS proceeds with the appropriate resolution for the dispute.
  • Once the dispute is resolved, parties will be notified by FHAS and the Departments via email correspondence of the outcome.
  

Reporting Any Issues:

Parties can contact the FHAS communication team regarding any concerns with the dispute review process.

 

For additional resources, see CMS.gov guidance below:

 

Download PDF of Resource

 

Legal Disclaimer

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 white paper 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.