Basic guidelines

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.

Initiating party documentation examples

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 using a DRG code)
  • CMS extension documentation confirming extension approval

Non-Initiating party documentation examples

In support of ineligibility

  • A full and complete Explanation of Benefits with detailed remark codes and Health Plan contact information visible
  • Initial Payment or Notice of Denial of Payment
  • Supporting materials to show when the initiating party initiated open negotiation
  • Any information which supports your assertion that the items or services under dispute are NOT eligible and qualified under the No Suprises Act (evidence reflecting the following: services in-network, applicable contracts, plan not in effect at time of service, state law applies, improper batching/bunding, cooling off period in effect)