Payment disputes between providers and health plans

Payment disputes between providers and health plans

The “No Surprises” rules create new protections against out-of-network balance billing and establish a new process, called the independent dispute resolution process, which providers (including air ambulance providers), emergency facilities and health plans can use to resolve payment disputes for certain out-of-network charges. These new protections begin on January 1, 2022, and ensure that providers, facilities and health plans can’t balance bill a consumer for certain out-of-network services. Instead, providers, facilities and health plans will use this independent dispute resolution process to determine the payment rates for those services.

When a provider or facility gets a payment denial notice or an initial payment from a health plan for certain out-of-network services, either the health plan or the provider or facility can choose to start an open negotiation period that lasts 30 business days. At the end of the 30-business-day period, if the health plan and provider or facility haven’t agreed on a payment amount, either party can begin the independent dispute resolution process.

The independent dispute resolution process:

  • Brings in a third-party known as a certified independent dispute resolution entity to decide the payment amount. The parties mutually select the certified independent dispute resolution entity, and everyone involved must attest to having no conflicts of interest.
  • Requires the provider or facility and the health plan to submit payment offers to the certified independent dispute resolution entity and additional information supporting their payment offers.
  • Requires the certified independent dispute resolution entity to select from the payment offers. Both the provider or facility and the health plan must abide by the certified entity’s decision, and payment must be made within 30 calendar days.

Parties to a dispute will use a new federal independent dispute resolution portal which will open in early 2022, after the first open negotiation periods between providers, facilities and health plans have concluded.

Not all items and services are subject to the independent dispute resolution process. For example, some states have their own processes to set prices for items and services or other laws that determine out-of-network payment amounts.

Get more information about the dispute resolution process and access resources, including model notices that can be used.

Page Last Modified:
01/14/2022 11:33 AM