Prop Regs Clarify No Surprises Act Dispute Resolution Process

The IRS, in conjunction with other government agencies, has issued proposed regs that clarify the federal independent dispute resolution (IDR) process in the No Surprises Act. (Preamble to Prop Reg REG-122319-22)

The No Surprises Act (NSA) enacted limitations on patient cost sharing and rules for group health care plans and health insurance issuers on timing initial payments and notices of denial of payment for emergency services furnished by out-of-network providers and facilities. These NSA limits and requirements also apply to nonemergency services furnished by out-of-network providers to patients visiting an in-network healthcare facility.

In addition, the NSA established an IDR process that out-of-network providers and plans may use to resolve disputes regarding out-of-network rates. The proposed regs address this IDR process, clarifying the IRS’s previously issued guidance on this subject.

The new proposals would:

• Impose new requirements on plans and issuers to disclose certain information along with the initial payment or notice of denial of payment for medical services covered by the surprise billing protections in the No Surprises Act.
• Require plans and issuers to communicate information by using claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs), when providing any remittance advice to an entity that does not have a contractual relationship with the plan or issuer.
• Amend certain requirements related to the open negotiation period preceding the IDR process, the initiation of the IDR process, the IDR dispute eligibility review, and the payment and collection of administrative fees and certified IDR entity fees.
• Define bundled payment arrangements, amend requirements related to batched items and services, and amend the rules for extensions of time frames due to extenuating circumstances.
• Require plans and issuers to register in the IDR portal.

Request for comments.

Comments must be received by January 3, 2024, to be considered. Comments should be submitted electronically at https://www.regulations.gov. When commenting, refer to file code RIN 0938-AV15 and follow the “Submit a comment” instructions.

For more information about the IDR process for out-of-network providers under the No Surprises Act, see Checkpoint’s Federal Tax Coordinator ¶ H-1325.72F.