Eligibility guidelines

Understanding bundling, batching, and cooling off rules in the IDR process

Bundling disputes involve combining related services into a single dispute, while batching rules permit grouping similar claims under specific criteria to streamline resolution. After a decision is made, a "cooling off period" prevents the same parties from submitting similar disputes for 90 days to discourage repetitive filings.

Bundled disputes

A bundled arrangement is an arrangement under which:

A provider, facility, or provider of air ambulance services bills for multiple items or services under a single service code; or
A plan 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 (e.g., a DRG).

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

Batching

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 batching rules align closely with those proposed by the Departments on October 27, 2023. Maximus has implemented the following criteria for batching claims (all three must be met):

The items and services are furnished by the same provider or facility
Payment for the items and services are made by the same group health plan or health insurance issue
Items and services were furnished during the 30-business day period (or 90-calendar day period if a cooling off period applies) following the date on which the first item or service included in the batched determination was furnished, and such items and services are related to the treatment of a similar condition*.

*Similar condition definition

Items and services related to the treatment of a similar condition must meet only one of the three of the following:

Single Patient Encounter Batching: Items/Services performed within the same patient encounter furnished on one or more consecutive days.
Identical service codes: Identical service codes relate to items and services billed under the same service code or a comparable code under a different procedural code system. This can be different patients.
For anesthesiology, radiology, pathology and laboratory, qualified IDR items and services would be considered to relate to the treatment of a similar condition when they are furnished under service codes belonging to the same Category I CPT code ranges.

Cooling off period

The “Cooling off period” is the 90-calendar day period following a payment determination when the initiating party cannot submit another Notice of IDR Initiation for the same or similar item or service involving the same non-initiating party from the previous payment determination.

Cooling Off period is applicable when the three criteria below are met:

Same parties
A payment determination was made on the previous dispute
The new dispute involves the same or similar items/services as the previous payment determination

A subsequent submission is permitted for the same or similar items or services if the end of the open negotiation period occurs during the 90-calendar-day cooling off period. For these items or services, either party must submit the Notice of IDR Initiation within 30 business days following the end of the cooling off period, as opposed to the standard 4-business-day period following the end of the open negotiation period. The 30-business-day period begins on the day after the last day of the cooling off period.

Note: If the End of Open Negotiation is before the date of the previous rendered payment determination, cooling off will not be applicable for the new Notice of IDR Initiation.