No Surprises Act Good Faith Estimates and Patient Provider Dispute Resolution

The No Surprises Act’s Good Faith Estimates and

Patient-Provider Dispute Resolution Requirements

Center for Consumer

Information & Insurance

Oversight (CCIIO)

Agenda

• Background: No Surprises Act Training Series

• Overview of the No Surprises Act Protections for Uninsured (or Self-Pay) Individuals

• Provision of Good Faith Estimates to Uninsured (or Self-Pay) Individuals

• Patient-Provider Dispute Resolution Process Requirements

• Questions

Legal Disclaimers

The information provided in this presentation is intended only to be a general informal

summary of technical legal standards. It is not intended to take the place of the statutes,

regulations, or formal policy guidance upon which it is based. This presentation summarizes

current policy and operations as of the date it was presented. We encourage readers to refer

to the applicable statutes, regulations, and other interpretive materials for complete and

current information.

Legal Disclaimers (continued)

The contents of this document do not have the force and effect of law and are not meant to

bind the public in any way, unless specifically incorporated into a contract. This document is

intended only to provide clarity to the public regarding existing requirements under the law.

This communication was printed, published, or produced and disseminated at U.S. taxpayer

expense.

Background: No Surprises Act Training Series

Overview of the No Surprises Act

The No Surprises Act* introduced new requirements for providers, facilities, and providers

of air ambulance services to protect individuals from surprise medical bills. These

requirements:

• Prohibit providers and facilities from directly billing individuals for the difference between the

amount they charge and the amount that the individual’s plan or coverage will pay plus the

individual’s cost-sharing amounts (i.e., balance billing) in certain circumstances;

• Require providers and facilities to provide good faith estimates of charges for care to uninsured

(or self-pay) individuals upon scheduling care or on request, and for individuals with certain types

of coverage, to submit good faith estimates to the individual’s plan or issuer;

• Create a patient-provider dispute resolution process for uninsured (or self-pay) individuals to

contest charges that are “substantially in excess” of the good faith estimate;

• Require certain providers and facilities to publicly disclose restrictions on balance billing; and

• Limit billed amounts in situations where a provider’s network status changes mid-treatment or

individuals act on inaccurate provider directory information.

* Title I (No Surprises Act) of Division BB of the Consolidated Appropriations Act, 2021 (CAA) amended title XXVII of the Public Health Service Act (PHS Act).

Scope of individuals protected under the

No Surprises Act

Beginning January 1, 2022, these No Surprises Act requirements will apply to items and

services provided to most individuals enrolled in private or commercial health coverage,

like:

• Employment-bas

group health plans (both self-insured and fully insured)

• Individual or group health coverage on or outside the Federal or State-based Exchanges

• Federal Employee Health Benefit (FEHB) health plans

• Non-federal governmental plans sponsored by state and local government employers

• Certain church plans within IRS jurisdiction

• Student health insurance coverage [as defined at 45 CFR 147.145]

Scope of individuals protected under the

No Surprises Act

(continued)

Some requirements also apply to providers and facilities with respect to uninsured (or self-

pay) individuals, like requirements that providers and facilities provide good faith estimates for

scheduled care, or upon request.

Requirements under the No Surprises Act don’t apply to beneficiaries or enrollees in

Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE.

These programs have other protections against high medical bills. The protections also don’t

apply to short-term limited duration insurance (STLDI), excepted benefits, or retiree-only

plans; or account-based group health plans.

No Surprises Act Training Series

The training

series is intended

to educate

providers and

facilities on these

major provisions

of the No

Surprises Act.

*Focus of today’s

presentation

Summary of Provision Statute and Regulatory Citation

Prohibition on balance billing for emergency services provided by out-of-network

providers or emergency facilities

PHS Act section 2799B-1

45 C.F.R § 149.410

Prohibition on balance billing for non-emergency services by out-of-network providers

at certain in-network health care facilities

PHS Act section 2799B-2

45 C.F.R. § 149.420

Prohibition on balance billing for air ambulance services by out-of-network air

ambulance service providers

PHS Act section 2799B-5

45 C.F.R. § 149.440

Public disclosure of individual protections against balance billing

PHS Act section 2799B-3

45 C.F.R. § 149.430

Restrictions on how much providers and facilities bill individuals in situations where the

provider’s or facility’s network contract with the individual’s plan or issuer is terminated

during continuing care

PHS Act section 2799B-8

Restrictions on how much providers and facilities bill individuals in situations where an

individual inadvertently receives care from an out-of-network provider or facility based

on inaccurate provider directory information

PHS Act section 2799B-9

*Provision of good faith estimates of charges to uninsured or self-pay

individuals in advance of scheduled items or services or upon request

PHS Act section 2799B-6

45 C.F.R. § 149.610

*The patient-provider dispute resolution process

PHS Act section 2799B-7

45 C.F.R § 149.620

The independent dispute resolution process

PHS Act section 2799A–1

45 C.F.R § 149.510

Overview of the No Surprises Act’s Protections for

Uninsured (or Self-Pay) Individuals

Effective January 1, 2022, the No Surprises Act

(NSA) protects uninsured (or self-pay)

individuals from many unexpectedly high medical bills.

• If an individual does not have certain types of health insurance, or does not plan to use that

insurance to pay for health care items or services, they are eligible to receive a “good faith

estimate” of what they may be charged, before they receive the item or service.

• A new patient-provider dispute resolution (PPDR) process is available for uninsured (or

self-pay) individuals who get a bill from a provider that is substantially in excess of the

expected charges on the good faith estimate.

*Enacted as part of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260).

Overview of the No Surprises Act’s Protections for

Uninsured (or Self-Pay) Individuals

(continued)

On October 7, 2021, HHS published interim final rules (IFR) titled Requirements Related to

Surprise Billing; Part II,

implementing various provisions of the NSA, including good faith

estimates and the PPDR process for payment determinations.

This presentation will focus on what information must be included in the good faith estimate

and the PPDR process.

*Requirements Related to Surprise Billing; Part II, 86 Fed. Reg. 55980 (October 7, 2021) codified at 45 CFR 149.610 & 149.620.

Good Faith Estimates for Uninsured (or Self-Pay)

Individuals

The good faith estimate (or GFE) is a notification that outlines an uninsured (or self-pay)

individual’s expected charges for a scheduled or requested item or service.

Providers and facilities must give this estimate to an uninsured (or self-pay) individual (or their

authorized representative) who requests it or who schedules an item or service.

The good faith estimate will also include items or services reasonably expected to be provided

along with the primary item(s) or service(s), even if the individual will receive the items and

services from another provider or another facility.

These requirements are applicable for good faith estimates requested on or after January 1,

2022 or for good faith estimates required to be provided in connection with items or services

scheduled on or after January 1, 2022.

Scope of providers that must comply with NSA

requirements pertaining to protections for uninsured (or

self-pay) individuals

For the purposes of the good faith estimate, a health care provider means a physician or

other health care provider who is acting within the scope of practice of that provider’s license

or certification under applicable State law, including a provider of air ambulance services.

The following types of health care providers must comply with the NSA’s good faith estimate

and PPDR requirements:

• Physicians;

• Other health care providers who are acting within their scope of practice under applicable

State law;

• Providers of air ambulance services.

Scope of facilities that must comply with NSA

requirements pertaining to protections for uninsured (or

self-pay) individuals

All health care institutions licensed under applicable state or local law are treated

as health care facilities that must comply with the NSA’s good faith estimate and

PPDR requirements including, for example:

• Hospitals;

• Hospital outpatient departments;

• Critical access hospitals;

• Ambulatory surgical centers;

• Rural health centers;

• Federally qualified health centers;

• Laboratory centers; and

• Imaging centers.

Scope of care included in good faith estimates

Under the NSA, uninsured (or self-pay)

individuals should receive a single,

comprehensive good faith estimate that

includes expected charges for:

• The primary item or service that will be

furnished by the convening provider or

convening facility and that is the initial

reason for the visit.

• All items and services that are reasonably

expected to be provided in conjunction

with the primary item or service, provided

during a defined period of care.

These items or services can include any of

the following:

• Encounters;

• Procedures;

• Medical tests;

• Supplies;

• Prescriptions drugs;

• Durable medical equipment; or

• Fees (including facility fees).

Example: Good faith estimate for knee surgery

If an individual schedules a knee surgery with their orthopedic surgeon, a good faith estimate

could include an itemized list of items or services in conjunction with and including the actual

knee surgery, such as:

• Physician professional fees;

• Assistant surgeon professional fees;

• Anesthesiologist professional fees;

• Facility fees;

• Prescription drugs; and

• Durable medical equipment fees.

Example: Good faith estimate for knee surgery (continued)

All the items or services that are reasonably expected to be provided from admission

through discharge

are part of that scheduled knee surgery period of care. These services or

items should be included in the good faith estimate.

Separate good faith estimates would be provided upon scheduling or upon request for any

items or services that are necessary prior to or following provision of the primary item or

service beyond the period of care

(e.g., pre-operative laboratory tests or post-discharge

physical therapy).

How expected charges are determined for a good

faith estimate

Expected charges included on a good faith estimate should be the cash pay rate or rate that

the uninsured (or self-pay) individual would be expected to pay for items or services listed on

the good faith estimate.

The expected charges should reflect true anticipated billed charges, including any anticipated

discounts or adjustments that a provider or facility would anticipate applying to the uninsured

(or self-pay) individual.

For example, the expected charges provided by a federally tax-exempt non-profit hospital

should apply any adjustments to billed charges that would be applied to an individual under

the hospital’s Financial Assistance Policy (FAP).

How expected charges are determined for a good

faith estimate

(continued)

In determining expected charges, providers and facilities are expected to use the coding that

best describes each item or service listed in the good faith estimate.

When a single service code is available that captures reporting and billing for the component

parts of an item or service, the single service code and expected charge for that single service

code would be reported in the good faith estimate to capture the most comprehensive coding

level.

The component parts would not be included in the good faith estimate as they would not be

separately reported or billed.

Convening provider or facility and co-provider or

co-facility

A convening provider or facility must provide a good faith estimate to the uninsured

individual, including any item or service that is reasonably expected to be provided in

conjunction with a scheduled or requested item or service by another provider or facility (co-

provider or co-facility).

As a result, the good faith estimate could contain expected charges from multiple providers:

the convening provider, and co-providers or co-facilities that furnish items and services that

are customarily provided in conjunction with a primary item or service.

For instance, if a patient schedules a surgery, the convening provider or facility might include

in the good faith estimate the cost of the surgery, and the co-provider or co-facility might

include the costs of any labs, tests, or anesthesia that might be used during the operation.

Knowledge Check

A provider is deciding which CPT codes to use for a laboratory test. The provider is

choosing between:

1. CPT code 85027 (complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet

count)), which represents a laboratory test that measures an individual’s hematocrit,

hemoglobin, red blood cell count, leukocyte (white blood cell) counts, and platelet

count.

2. Individual CPT codes for each of the component parts of the service represented by

CPT code 85027 (CPT codes: 85014 (hematocrit (Hct)), 85018 (hemoglobin (Hgb)),

85041 (red blood cell (RBC), automated), 85048 (leukocyte (WBC), automated), and

85049 (platelet, automated)).

In order to remain compliant with the NSA, which option would best describe the

item or service for use in the good faith estimate?

Knowledge Check Answer

HHS expects that the good faith estimate would include expected charges for CPT

code 85027, not expected charges for each component part since there is a single

CPT code available that better captures reporting for all of the component parts of

the laboratory service.

When a single service code is available that captures reporting and billing for the

component parts of an item or service, the single service code and expected charge for that

single service code would be reported in the good faith estimate to capture the most

comprehensive coding level.

Informing uninsured (or self-pay) individuals

A convening provider or facility must inform all uninsured (or self-pay) individuals of the

availability of a good faith estimate of expected charges upon scheduling an item or service or

upon request. To determine if someone is an uninsured (or self-pay) individual, the provider or

facility must ask if the individual is enrolled in:

• A group health plan,

• Group health insurance coverage offered by a health insurance issuer,

• A Federal health care program, or

• A health benefits plan under a Federal Employees Health Benefits (FEHB) Program.

Informing uninsured (or self-pay) individuals (continued)

If not enrolled in any of the above, the individual is considered uninsured for the purposes of

the good faith estimate.

If the individual is enrolled in a group health plan, group or individual health insurance

coverage offered by a health insurance issuer, or a FEHB health benefits plan, the convening

provider or facility must ask if the individual is seeking to have a claim submitted for the items

or services with such plan or coverage. If not, the individual is considered self-pay for the

purposes of the good faith estimate.

Distribution and display of the good faith estimate to

individuals

• Information regarding the availability of good faith estimates for uninsured (or self-pay)

individuals must be written in a clear and understandable manner

, prominently

displayed (and easily searchable from a public search engine) on the convening

prov

ider’s or convening facility’s website, in the office, and on-site where scheduli

questions about the cost of items or services occur.

• Convening providers and facilities must also give information about the good faith estimate

for uninsured (or self-pay) individuals when scheduling an item or service or when questions

about the cost of items or services occur.

• Convening providers and convening facilities must consider any discussion or inquiry

regarding the potential costs of items or services under consideration as a request for a

good faith estimate.

Timeframes

Upon receiving a request for a good faith estimate from an uninsured (or self-pay) individual

or upon scheduling a primary item or service for an uninsured (or self-pay) individual, the

convening provider or convening facility must contact all co-providers and co-facilities who are

reasonably expected to provide items or services in conjunction with, and in support of, the

primary item or service no later than 1 business day after scheduling or receiving the request.

The convening provider or convening facility must request that the co-providers or co-facilities

submit good faith estimate information to the convening provider or facility.

Timeframes (continued 1)

Convening providers and facilities must provide a good faith estimate to uninsured (or self-

pay) individuals within the following timeframes:

• When a primary item or service is scheduled at least 3 business days before the date the

item or service is scheduled to be furnished, the good faith estimate must be provided no

later than 1 business day after the date of scheduling.

• When a primary item or service is scheduled at least 10 business days before such item or

service is scheduled to be furnished, the good faith estimate must be provided no later than

3 business days after the date of scheduling.

• When a good faith estimate is requested by an uninsured (or self-pay) individual, the good

faith estimate must be provided no later than 3 business days after the date of the request.

Timeframes (continued 2)

HHS recognizes that some providers or facilities may need to establish efficient and secure

communication channels for transmission of good faith estimate information between

convening providers or facilities and co-providers and co-facilities.

It is also understood that it may take time for providers and facilities to develop systems and

processes for receiving and providing the required information from co-providers and co-

facilities.

Therefore, for good faith estimates provided to uninsured (or self-pay) individuals from

January 1, 2022 through December 31, 2022, HHS will exercise its enforcement discretion in

situations where a good faith estimate provided to an uninsured (or self-pay) individual does

not include expected charges from co-providers or co-facilities.

Timeframes (continued 3)

A co-provider or co-facility is not prohibited from furnishing the information before December

31, 2022, and nothing would prevent the uninsured (or self-pay) individual from separately

requesting a good faith estimate directly from the co-provider or co-facility, in which case the

co-provider and co-facility would be required to provide the good faith estimate for such items

or services.

Otherwise, during this period, HHS encourages convening providers and convening facilities

to include a range of expected charges for items or services reasonably expected to be

provided and billed by co-providers and co-facilities.

Changes to the scope of the good faith estimate

If a convening provider, convening facility, co-provider, or co-facility anticipates or is notified of

any changes to the scope of a good faith estimate (such as anticipated changes to the

expected charges, items, services, frequency, recurrences, duration, providers, or facilities)

previously furnished at the time of scheduling, the convening provider or convening facility

must provide the individual with a new good faith estimate no later than 1 business day before

the items or services are scheduled to be furnished.

If any changes in expected providers or facilities represented in a good faith estimate occur

less than 1 business day before the item or service is scheduled to be furnished, the

replacement provider or facility must accept the good faith estimate for the relevant items or

services being furnished that was provided by the replaced provider or facility.

Changes to the scope of the good faith estimate (continued)

For good faith estimates provided upon request of an uninsured (or self-pay) individual, upon

scheduling of the requested item or service, the convening provider or convening facility must

provide the individual with a new good faith estimate for the scheduled item or service within

the standard timeframes specified in the Timeframes section of this presentation.

Good faith estimate for recurring primary items or

services

A convening provider or convening facility may issue a single good faith estimate for

recurring primary items or services if both of the following requirements are met:

• The good faith estimate for recurring items or services includes, in a clear and

understandable manner, the expected scope of the recurring primary items or services

(such as timeframes, frequency, and total number of recurring items or services).

• The scope of a good faith estimate for recurring primary items or services does not exceed

12 months.

Requirements for co-providers and co-facilities

Co-providers and co-facilities must submit good faith estimate information upon the request

of the convening provider or convening facility. The co-provider or co-facility must provide, and

the convening provider or convening facility must receive, the good faith estimate information

no later than 1 business day after the co-provider or co-facility receives the request from the

convening provider or convening facility.

Co-providers and co-facilities must notify and provide new good faith estimate information to a

convening provider or convening facility if the co-provider or co-facility anticipates any

changes to the scope of good faith estimate information previously submitted to a convening

provider or convening facility (such as anticipated changes to the expected charges, items,

services, frequency, recurrences, duration, providers, or facilities).

Requirements for co-providers and co-facilities (continued)

If any changes to the co-providers or co-facilities listed in the good faith estimate occur less

than 1 business day before the item or service is scheduled to be furnished, the replacement

co-provider or co-facility must accept as its good faith estimate of expected charges the good

faith estimate for the relevant items or services included in the good faith estimate provided by

the replaced provider or facility.

In the event that an uninsured (or self-pay) individual separately schedules or requests a good

faith estimate from a provider or facility that would otherwise be a co-provider or co-facility,

that provider or facility must meet all requirements that apply to convening providers and

convening facilities for issuing a good faith estimate to the individual.

Content requirements of a good faith estimate issued

to an uninsured (or self-pay) individual

A good faith estimate issued to an uninsured (or self-pay) individual must include:

• Patient name and date of birth

• Description of the primary item or service in clear and understandable language (and if

applicable, the date the primary item or service is scheduled)

• Itemized list of items or services, grouped by each provider or facility, reasonably expected

to be furnished for the primary item or service, and items or services reasonably expected to

be furnished in conjunction with the primary item or service, for that period of care including

both:

– Items or services reasonably expected to be furnished by the convening provider or

convening facility for the period of care

– Items or services reasonably expected to be furnished by co-providers or co-facilities

Content requirements of a good faith estimate issued

to an uninsured (or self-pay) individual

(continued 1)

• Applicable diagnosis codes, expected service codes, and expected charges associated

with each listed item or service

• Name, National Provider Identifier, and Tax Identification Number of each provider or

facility represented in the good faith estimate, and the state(s) and office or facility location(s)

where the items or services are expected to be furnished by such provider or facility

Content requirements of a good faith estimate issued

to an uninsured (or self-pay) individual

(continued 2)

• List of items or services that the convening provider or convening facility anticipates

will require separate scheduling and that are expected to occur before or following the

expected period of care for the primary item or service. The good faith estimate must include

a disclaimer directly above this list that includes all of the following information:

– Separate good faith estimates will be issued to an uninsured (or self-pay) individual upon

scheduling or upon request of the listed items or services

– Notification that for items or services included in this list, information such as diagnosis

codes, service codes, expected charges and provider or facility identifiers, do not need to

be included as that information will be provided in separate good faith estimates upon

scheduling or upon request of such items or services

– Instructions for how an uninsured (or self-pay) individual can obtain good faith estimates

for such items or services

Content requirements of a good faith estimate issued

to an uninsured (or self-pay) individual

(continued 3)

• A disclaimer that informs the uninsured (or self-pay) individual that there may be additional

items or services the convening provider or convening facility recommends as part of the

course of care that must be scheduled or requested separately and are not reflected in the

good faith estimate

• A disclaimer that informs the uninsured (or self-pay) individual that the information provided

in the good faith estimate is only an estimate regarding items or services reasonably

expected to be furnished at the time the good faith estimate is issued to the uninsured (or

self-pay) individual and that actual items, services, or charges may differ from the good faith

estimate

Content requirements of a good faith estimate issued

to an uninsured (or self-pay) individual

(continued 4)

• A disclaimer that informs the uninsured (or self-pay) individual of that individual’s right to

initiate the PPDR process if the actual billed charges are substantially in excess of the

expected charges included in the good faith estimate. This disclaimer must include

instructions for where the individual can find information about how to initiate the PPDR

process and state that the initiation of the PPDR process will not adversely affect the quality

of health care services furnished to the individual by a provider or facility

• A disclaimer that the good faith estimate is not a contract and does not require the uninsured

(or self-pay) individual to obtain the items or services from any of the providers or facilities

identified in the good faith estimate (

example disclaimer notice can be found here

)

HHS model notice and template

HHS has developed a model template and notice that providers and facilities may use to

prepare good faith estimates for uninsured (or self-pay) individuals and to notify uninsured (or

self-pay) individuals of the availability of a good faith estimate.

Use of this model notice is not required and is provided as a means of facilitating compliance

with the applicable notice requirements.

This model notice and template were published as part of

CMS Form Number 10791

and are

available for download.

HHS model notice and template (continued)

Content requirements for good faith estimate information

submitted by co-providers or co-facilities to convening

providers or convening facilities

Good faith estimate information submitted to convening providers or convening facilities by co-

providers or co-facilities for inclusion in the good faith estimate must include:

• Patient name and date of birth

• A list of items or services expected to be provided by the co-provider or co-facility that are

reas

onably expected to be furnished in conjunction with the primary item or service as part of

the period of care

• Applicable diagnosis codes, expected service codes, and expected charges associated

with each listed item or service

• Name, National Provider Identifiers, and Tax Identification Numbers of the co-provider or

co-facility, and the state(s) and office or facility location(s) where the items or services are

expected to be furnished by the co-provider or co-facility

• A disclaimer that the good faith estimate is not a contract and does not require the uninsured

(or self-pay) individual to obtain the items or services from any of the co-providers or co-

facilities identified in the good faith estimate

Required methods for providing good faith estimates

for uninsured (or self-pay) individuals

A good faith estimate must be provided in written form either on paper or electronically,

pursuant to the uninsured (or self-pay) individual’s requested method of delivery, and within the

timeframes described above. Good faith estimates provided electronically must be provided in a

manner that the uninsured (or self-pay) individual can both save and print. Good faith estimates

provided to uninsured (or self-pay) individuals by paper mail must be postmarked by the

timelines specified in the Timeframes section of this presentation.

A good faith estimate must be provided and written using clear and understandable language.

Additional requirements

A good faith estimate issued to an uninsured (or self-pay) individual under this section is

considered part of the patient’s medical record and must be maintained in the same manner

as a patient’s medical record. Convening providers and convening facilities must provide a copy

of any previously issued good faith estimate furnished within the last 6 years to an uninsured (or

self-pay) individual upon request by the individual.

For all providers or facilities that issue good faith estimates following their state’s processes and

rules, if those state processes and rules do not meet federal good faith estimate requirements,

those providers and facilities have failed to comply with federal good faith estimate

requirements.

Additional requirements (continued 1)

A provider or facility will not fail to comply with federal good faith estimate requirements solely

because, despite acting in good faith and with reasonable due diligence, the provider or facility

makes an error or omission in a required good faith estimate, provided that the provider or

facility corrects the information as soon as practicable. If items or services are furnished before

an error in a good faith estimate is addressed, the provider or facility may be subject to PPDR if

the actual billed charges are substantially in excess of the good faith estimate (as described

later in this presentation).

Additional requirements (continued 2)

To the extent compliance with federal good faith estimate requirements requires a provider or

facility to obtain information from any other entity or individual, the provider or facility will not fail

to comply with this section if it relied in good faith on the information from the other entity,

unless the provider or facility knows, or reasonably should have known, that the information is

incomplete or inaccurate. If the provider or facility learns that the information is incomplete or

inaccurate, the provider or facility must provide corrected information to the uninsured (or self-

pay) individual as soon as practicable. If items or services are furnished before an error in a

good faith estimate is addressed, the provider or facility may be subject to PPDR if the actual

billed charges are substantially in excess of the good faith estimate.

Example of how itemized lists of expected items or

services could be displayed in a good faith estimate

for uninsured (or self-pay) individuals

Details of Services and Items for [Provider/Facility 1]

Service/Item

Address where service/item

will be provided

Diagnosis Code Service Code Quantity Expected Cost

[Street, City, State, ZIP] [ICD code]

[Service Code

Type: Service Code

Number]

- -

- - - - - -

Total Expected Charges from [Provider/Facility 1] $

Additional Health Care Provider/Facility Notes

Example of how itemized lists of expected items or

services could be displayed in a good faith estimate

for uninsured (or self-pay) individuals

(continued)

Details of Services and Items for [Provider/Facility 2]

These additional Provider/Facility costs may not be included until 2023

Service/Item Address where service/item

will be provided

Diagnosis Code Service Code Quantity Expected Cost

[Street, City, State, ZIP] [ICD code] [Service Code

Type: Service Code

Number]

- -

- - - - - -

Total Expected Charges from [Provider/Facility 2] $

Additional Health Care Provider/Facility Notes

Patient-Provider Dispute Resolution (PPDR) Process

Beginning January 1, 2022, a PPDR process will be available for uninsured (or self-pay)

individuals who get a bill for an item or service that is substantially in excess of the expected

charges on the good faith estimate. Under the PPDR process, the uninsured (or self-pay)

individual may seek a determination from a Selected Dispute Resolution (SDR) entity for the

amount the individual has to pay. This process can provide the uninsured (or self-pay) individual

important consumer protections from billed charges that are substantially in excess of the

expected charges in the good faith estimate.

Items or services eligible for PPDR

The PPDR process can apply to any item or service furnished by a convening provider,

convening facility, co-provider, or co-facility to an uninsured (or self-pay) individual where the

total billed charges are substantially in excess of the total expected charges in the good faith

estimate.

HHS regulations establish that when the billed charges for any provider or facility are in

excess of the good faith estimate for that provider or facility by $400 or more, the item or

service may be eligible for payment determination by a SDR entity through the PPDR

process.

As each good faith estimate could potentially contain expected charges from multiple providers

and facilities, the substantially in excess determination is made separately for each specific

provider or facility listed on the good faith estimate.

Items or services eligible for PPDR (continued)

If a co-provider or co-facility that provided an estimate of the expected charge for an item or

service in the good faith estimate is replaced by a different co-provider or co-facility less than

1 business day before that item or service is scheduled to be furnished, an item or service

billed by the replacement co-provider or co-facility is eligible for dispute resolution if the billed

charge is $400 or more than the total expected charges included in the good faith estimate for

the original co-provider or co-facility.

If the replacement provider or facility provides the uninsured (or self-pay) individual with a new

good faith estimate, in a timely manner, then the determination of whether an item or service

billed by the replacement co-provider or co-facility is eligible for dispute resolution is based on

whether the total billed charge for the replacement co-provider or co-facility is $400 or more

than the total expected charges included in the good faith estimate provided by the

replacement co-provider or co-facility.

Knowledge Check

Tonya is a 40-year-old female with a long history of right knee pain. She does not have any

form of health insurance. Tonya schedules an appointment with her orthopedist to receive a

cortisone injection in her knee. Upon scheduling the appointment, her orthopedist sends

her a good faith estimate. The good faith estimate lists the total expected charges of $300

for the procedure. Tonya undergoes the injection and subsequently receives a bill from the

orthopedist. The total billed charge is $850.

Would Tonya be eligible to pursue the PPDR process?

Knowledge Check Answer

Yes, Tonya would be eligible to pursue the PPDR process.

Tonya is uninsured, and the total billed charge is considered substantially in excess of the

good faith estimate, since the difference between the total expected and total billed charges

is greater than or equal to $400. Under the NSA, in order to be eligible to pursue the PPDR

process, an individual must be considered uninsured or self-pay, the total billed charges by

the particular convening provider, convening facility, co-provider, or co-facility, must be

substantially in excess ( >

$400) of the total expected charges for that specific provider or

facility listed in the good faith estimate, and the date of the bill must be within 120 days.

Enforcement discretion in 2022 for expected charges for

items and services from a co-provider or co-facility

For good faith estimates provided to uninsured (or self-pay) individuals on or after January 1,

2022 through December 31, 2022, HHS will exercise its enforcement discretion in situations

where the good faith estimate does not include expected charges for items and services from

a co-provider or co-facility.

During the period of enforcement discretion, items or services to be provided by a co-provider

or co-facility that appear on the good faith estimate that do not include an estimate of

expected charges or that appear as a range of expected charges would not be eligible for the

PPDR process for the item or service provided by the co-provider or co-facility.

Would a provider or facility be subject to requirements for

the PPDR process but not requirements for the good faith

estimate?

The good faith estimate requirements work together with the PPDR requirements to establish

important consumer protections for uninsured (or self-pay) individuals who receive billed

charges that are substantially in excess of the good faith estimates they received prior to

scheduling (or upon request of) items or services. As a result, the requirements for the PPDR

process apply to all providers or facilities subject to the good faith estimate requirements.

How is PPDR eligibility determined when there are

different providers or facilities listed on the same good

faith estimate?

Eligibility for PPDR is determined separately for each unique provider or facility listed on the

good faith estimate. For each provider or facility, the total expected charges for each item or

service should be added up. This total amount is then compared with the total of all billed

charges for the provider or facility, including billed charges for items and services that were

furnished but not included in the good faith estimate, to determine eligibility for PPDR.

How is PPDR eligibility determined when there are

different providers or facilities listed on the same good

faith estimate?

(continued 1)

Example 1

In example 1, the good faith estimate contains two providers, A and B. The total expected

charges for both providers A and B equal $2625, however for purposes of PPDR the total of

expected charges are separated by provider. In this case, the total expected charges for

provider A are $2125 and the total expected charges for provider B are $500. The billed

charges for providers A and B respectively are compared with their total expected charges to

determine whether the billed charges are eligible for PPDR as shown in example 2.

Provider Item or Service Expected charge

Provider A Item 1 $300

- Item 2 $1275

- Item 3 $550

Total Expected Charges from Provider A $2125

Provider B Item 1 $500

Total Expected Charges from Provider B $500

How is PPDR eligibility determined when there are

different providers or facilities listed on the same good

faith estimate?

(continued 2)

Example 2

In example 2, even though the total of all billed charges for provider A ($2400) is greater than

the total of expected charges ($2125), the difference between the billed charges and expected

charges are less than $400. As a result, items provided by provider A are not eligible for PPDR.

Provider A Expected charge Billed charge

Item 1 $300 $350

Item 2 $1275 $1500

Item 3 $550 $550

Total $2125 $2400

How is PPDR eligibility determined when there are

different providers or facilities listed on the same good

faith estimate?

(continued 3)

Example 3

In example 3, the total of all billed charges for provider A ($2700) is greater than the total of

expected charges ($2125), and the difference between the billed charges and expected

charges are greater than $400. As a result, items provided by provider A are eligible for PPDR.

Provider A Expected charge Billed charge

Item 1 $300 $350

Item 2 $1275 $1500

Item 3 $550 $850

Total $2125 $2700

How is PPDR eligibility determined when there are

different providers or facilities listed on the same good

faith estimate?

(continued 4)

Example 4

In example 4, the uninsured individual was billed by provider A for an item that did not appear

on the good faith estimate, item 4. Even though item 4 is not included in the total expected

charges as it did not appear on the good faith estimate, the billed charge for item 4 is included

in the total billed charges. As the total billed charges exceed the total expected charges by $400

or more, items provided by provider A are eligible for PPDR.

Provider A Expected charge Billed charge

Item 1 $300 $350

Item 2 $1275 $1500

Item 3 $550 $550

Item 4 NA $200

Total $2125 $2600

Initiating the PPDR process

An uninsured (or self-pay) individual, or their authorized representative, can initiate the PPDR

process by submitting an initiation notice to HHS through the online federal IDR portal,

submitting an initiation notice electronically, or submitting through the mail if postmarked within

120 calendar days of receiving the initial bill containing charges for the item or service that is

substantially in excess of the expected charges in the good faith estimate.

HHS strongly recommends that the initiation notice be submitted through the

federal

IDR portal to help ensure the request can be processed quickly and securely.

The initiation notice

When an uninsured (or self-pay) individual is billed for items or services where the total billed

charges for a provider or facility are $400 or more above the total expected charges for the

provider or facility in the good faith estimate, the uninsured (or self-pay) individual or their

authorized representative, may submit a notification (initiation notice) to HHS to initiate the

PPDR process. The initiation notice must include all of the following:

• Information sufficient to identify the items or services under dispute, including:

a. The date of service or date the item was provided

b. A description of the item or service

• A copy of the bill for the items and services under dispute (the copy can be a photocopy or an

electronic image so long as the document is readable)

• Last 4 digits of the account number on the bill

• A copy of the good faith estimate for the items and services under dispute (the copy can be a

photocopy or an electronic image so long as the document is readable)

The initiation notice (continued)

• The contact information of the parties involved, including:

a. Name,

b. Email address,

c. Phone number, and

d. Mailing address.

• The state where the items or services in dispute were furnished, and

• The uninsured (or self-pay) individual’s contact information including:

a. Name,

b. Email address,

c. Phone number,

d. Mailing address, and

e. Communication preference: email, paper mail, or phone.

What is the administrative fee and how does it work?

HHS has established a $25 administrative fee to participate in the PPDR process in 2022.

The fee amount is meant to ensure there is no barrier to an uninsured (or self-pay) individual’s

ability to access this process. The administrative fee is an amount paid by the individual to use

the PPDR process to settle payment disputes with providers and facilities. HHS will assess

the $25 administrative fee in 2022 on the non-prevailing party (providers, facilities, and

uninsured (or self-pay) individuals) to the PPDR process.

The uninsured (or self-pay) individual will pay the administrative fee at the beginning of the

process to the SDR entity. Providers and facilities are not required to pay the $25

administrative fee upfront. If the SDR entity determines the payment amount to be lower than

the billed charges, the SDR entity will apply an adjustment to the final payment determination

amount to allow for the individual to recover the $25 paid.

What is the administrative fee and how does it work?

(continued)

The amount of the administrative fee may change in future years, but any such change will be

promulgated in advance by additional guidance. For more information on the PPDR

administrative fee see

PPDR fee guidance

Prohibition on collections and retributive action

While the PPDR process is pending, the provider or facility must not move the bill for the

disputed item or service into collection or threaten to do so, or if the bill has already moved

into collection, the provider or facility should cease collection efforts. The provider or facility

must also suspend the accrual of any late fees on unpaid bill amounts until after the PPDR

process has concluded. Finally, the provider or facility must not take or threaten to take any

retributive action against an uninsured (or self-pay) individual for utilizing the PPDR process to

seek resolution for a disputed item or service.

The online federal IDR portal

When practicable, providers and facilities should use the online federal IDR portal to submit

documentation for the PPDR process. The federal IDR portal is the same portal used for the

federal IDR process (i.e., payer-provider and payer-air ambulance provider processes).

Providers and facilities may also receive notices from HHS and the SDR entity, submit

additional supporting documents, and receive the SDR entity’s determination via email. More

information on the federal IDR portal can be found on the

portal webpage

PPDR process following SDR receipt of initiation

notice

The SDR entity will review the initiation notice submitted by the uninsured (or self-pay)

individual to ensure that the items or services in dispute meet the eligibility criteria for the

PPDR process and that the initiation notice contains all the required information. Once the

SDR entity has determined that an item or service is eligible for dispute resolution and that the

initiation notice contains all the required information, the SDR entity will notify the uninsured

(or self-pay) individual and the provider or facility through the federal IDR portal, or electronic

or paper mail, or phone, that a PPDR initiation request has been received and is under review.

PPDR process following SDR receipt of initiation

notice

(continued 1)

Additionally, the SDR entity will notify the provider or facility that they must provide certain

information within 10 business days. HHS strongly recommends that this information be

submitted using the federal IDR portal. This information must include all of the following:

• A copy of the good faith estimate provided to the uninsured (or self-pay) individual for the

items or services under dispute (the copy can be a photocopy or an electronic image so long

as the document is readable);

• A copy of the billed charges provided to the uninsured (or self-pay) individual for items or

services under dispute (the copy can be a photocopy or an electronic image so long as the

document is readable); and

• If available, documentation providing evidence to demonstrate that the difference

between the billed charges and the expected charges in the good faith estimate reflects

the costs of a medically necessary item or service and is based on unforeseen circumstances

that could not have reasonably been anticipated by the provider or facility when the good faith

estimate was provided.

PPDR process following SDR receipt of initiation

notice

(continued 2)

No later than 30 business days after receiving this information, the SDR entity must make a

determination regarding the amount to be paid by the uninsured (or self-pay) individual.

The SDR entity will also notify the uninsured (or self-pay) individual in cases where the

initiation notice is determined to be incomplete or the item or service is determined ineligible

for dispute resolution, in which case the uninsured (or self-pay) individual would be provided

21 calendar days to submit any missing information or provide supplemental information to

demonstrate the item or service is eligible for the PPDR process.

See the previous examples of calculating eligibility provided earlier in this presentation.

Knowledge Check

Tom is a 30-year-old male with a history of a chronic cholecystitis, which has become

progressively more symptomatic over time. He does not have health insurance of any kind. Tom

is advised to schedule a laparoscopic cholecystectomy with the general surgeon. He schedules

the surgery with the general surgeon. The provider sends Tom a good faith estimate for the

surgery, which includes good faith estimates from the general surgeon and the anesthesiologist.

The total expected charges for the general surgeon are $2,000. Tom undergoes the surgery.

During the surgery, the surgeon determines that the surgery must be converted to an open

cholecystectomy, due to multiple adhesions to surrounding tissue. As a result, the surgery takes

much longer than anticipated. Tom must stay inpatient for several days. Several weeks later,

Tom receives a bill from the surgeon with total billed charges of $3,600.

Tom submits an initiation notice to HHS to initiate the PPDR process and the assigned SDR

entity determines that the total billed charges are eligible for review under the PPDR process.

Under the NSA, what information must the provider furnish to the SDR entity?

Knowledge Check Answer

The provider must submit a copy of the good faith estimate and a copy of the billed

charges. They must also submit documentation providing evidence to demonstrate

that the difference between the billed charges and the expected charges in the good

faith estimate reflects the costs of a medically necessary item or service and is

based on unforeseen circumstances that could not have reasonably been anticipated

by the provider or facility when the good faith estimate was provided.

How does the SDR entity make the determination?

The SDR entity will review the billed charges to see if the items and services were included

on the good faith estimate, as well as review all documentation timely submitted by the parties,

including the uninsured (or self-pay) individual or their authorized representative and the

provider or facility.

The SDR entity will determine how much the uninsured (or self-pay) individual must pay based

on documentation submitted by the provider or facility; whether the provider or facility has

provided credible information to demonstrate that the difference between the billed charge and

the expected charge for the item or service in the good faith estimate reflects the costs of a

medically necessary item or service and is based on unforeseen circumstances that could not

have reasonably been anticipated by the provider or facility when the good faith estimate was

provided.

The SDR entity will make this assessment separately for each unique billed item or service.

Examples of determining the payment amount

1. For any item or service where the billed charge is equal to or less than the

expected charge in the good faith estimate, the SDR entity would determine that the

billed amount is not substantially in excess of the good faith estimate and this case is not

eligible for the PPDR process. The SDR entity would inform the patient or their authorized

representative that they are ineligible for this dispute resolution process.

Example: billed charge $500; expected charge $975. The SDR entity would inform the

patient or their authorized representative that this case is ineligible for resolution via the

PPDR process.

Examples of determining the payment amount (continued 1)

2. For a billed item or service that was included on the good faith estimate, if the

billed charge for an item or service is substantially in excess of the expected

charge in the good faith estimate, and the SDR entity determines the provider or facility

has not provided credible information that the difference between the billed charge and

the good faith estimate reflects the costs of a medically necessary item or service and is

based on unforeseen circumstances that could not have reasonably been anticipated by

the provider or facility when the good faith estimate was provided, the SDR entity must

determine the amount to be paid by the uninsured (or self-pay) individual for the item or

service to be equal to the good faith estimate amount.

Example: billed charge $875; expected charge $450. The payment amount will be $450.

Examples of determining the payment amount (continued 2)

3. If the SDR entity determines that the provider or facility has provided credible

information that the difference between the billed charge and the expected charge

in the good faith estimate reflects the cost of a medically necessary item or service

and is based on unforeseen circumstances, the SDR entity must select as the amount

to be paid by the uninsured (or self-pay) individual the lesser of: (1) the billed charge; or

(2) the median payment amount paid by a plan or issuer for the same or similar service,

by a same or similar provider in the geographic area as defined in § 149.140(a)(7) where

the services were provided, that is reflected in an independent database as defined in §

149.140(a)(3) using the methodology described in § 149.140(c)(3), except that in cases

where the amount determined by an independent database is determined to be less than

the expected charge for the item or service listed on the good faith estimate, the amount

to be paid will equal to the expected charge for the item or service listed on the good faith

estimate. When comparing the billed charge with the amounts contained in an

independent database, the SDR entity should account for any discounts offered by the

provider or facility.

Examples of determining the payment amount (continued 3)

Example: billed charge $900; expected charge $450

If the SDR entity determines that the provider did provide credible information justifying the

higher charge, the payment amount for the item will be the lower of: $900; or the median

payment amount described above, or if lower than the good faith estimate, the good faith

estimate ($450).

PPDR Process: Payment determination

Once the SDR entity determines whether the billed charges are justified, the SDR entity must

determine the final payment amount for each item or service billed by the provider or facility,

using the following rules.

For any item or service that appears

on the good faith estimate:

Billed Charge for an Item or Service

Credible Information Provided to Justify

Charges

Amount to be Paid

Less than or equal to expected charge N/A

Billed charge (and not eligible for PPDR

process)

Greater than expected charge No Expected charge

Greater than expected charge Yes

The lesser of:

1. Billed charge or

2. Median payment amount paid by a plan

or issuer for the same or similar service,

by a same or similar provider in the

geographic area where services were

provided.

What about items not originally on the good faith

estimate?

For billed items or services not listed on the good faith estimate, if the SDR entity determines

the provider or facility did not provide credible information that demonstrates that the

difference between the billed charge for the new item or service and the good faith estimate

reflects the costs of a medically necessary item or service and is based on unforeseen

circumstances that could not have reasonably been anticipated by the provider or facility when

the good faith estimate was provided, then the SDR entity must determine that amount to be

paid for the new item or service to be equal to $0.

What about items not originally on the good faith

estimate?

(continued 1)

If the SDR entity determines that a provider or facility has provided credible information that the

billed charge for new items or services that did not appear on the good faith estimate does

reflect the costs of a medically necessary item or service and is based on unforeseen

circumstances that could not have reasonably been anticipated by the provider or facility when

the good faith estimate was provided, then the SDR entity must determine the charge to be

paid by the uninsured (or self-pay) individual for the new item or service as the lesser of:

1. The billed charge, or

2. The median payment amount paid by a plan or issuer for the same or similar service, by a

same or similar provider in the geographic area as defined in § 149.140(a)(7) where the

services were provided, that is reflected in an independent database as defined in §

149.140(a)(3) using the methodology described in § 149.140(c)(3). When comparing the

billed charge with the amounts contained in an independent database, the SDR entity

should account for any discounts offered by the provider or facility.

What about items not originally on the good faith

estimate?

(continued 2)

After making a determination about each item and service subject to the PPDR, the SDR entity

will add together the amounts to be paid for all items and services subject to the determination.

In cases where the final amount determined by the SDR entity is lower than the billed charge,

the SDR entity will reduce the final amount by the administrative fee amount paid by the

individual.

For any item or service that DOES NOT appear on the good faith estimate

(e.g., new item or service):

Credible Information Provided to Justify Charges Amount to be Paid

No $0

Yes

The lesser of:

1. Billed charge or

2. Median payment amount.

Can providers and facilities settle their payment dispute

with uninsured (or self-pay) individuals during the PPDR

process?

Yes. HHS recognizes that the two parties to the PPDR process (the uninsured (or self-pay)

individual and the provider or facility) may agree to resolve the dispute by settling on a

payment amount.

At any point after the PPDR process has been initiated but before the date on which a

determination is made by the SDR entity, the parties can settle the payment amount through

either an offer of financial assistance or an offer to accept a lower amount, or an agreement by

the uninsured (or self-pay) individual to pay the billed charges in full.

Can providers and facilities settle their payment dispute

with uninsured (or self-pay) individuals during the PPDR

process?

(continued)

In the event that the parties agree to settle on a payment amount, the provider or facility

should notify the SDR entity through the federal IDR Portal, electronically, or in paper form, as

soon as possible, but no later than 3 business days after the date of the agreement.

Once the SDR entity receives the notification of the settlement, the SDR entity must close the

dispute resolution case as settled and the agreed upon payment amount will apply.

Knowledge Check

Maria is a 25-year-old female self-pay individual. She has an appointment with her

gynecologist to discuss long acting reversible contraceptives. Maria decides to schedule a

procedure to have an intrauterine device placed. Upon scheduling the appointment, her

gynecologist sends her a good faith estimate, which includes a total expected charge of

$400. Maria undergoes the procedure. Several weeks later she receives a bill for $850.

Maria submits an initiation notice to HHS. However, before the SDR entity makes a

determination, Maria instead agrees to pay the billed charges in full.

Are parties allowed to settle a dispute outside of the PPDR process?

Knowledge Check Answer

Yes, parties are allowed to settle the payment amount after the PPDR process has

been initiated but before a determination is made. The parties can settle the payment

amount through:

• An offer of financial assistance;

• An offer to accept a lower amount; or,

• An agreement by the uninsured (or self-pay) individual to pay the billed charges in

full.

If the parties agree to settle, the provider or facility must provide a settlement

notification to the SDR entity no later than 3 business days after the date of the

agreement.

Treatment of payments made prior to determination

Payment of the billed charges (or a portion of the billed charges) by the uninsured (or self-

pay) individual (or by another party on behalf of the uninsured (or self-pay) individual) prior to

a determination does not demonstrate agreement by the individual to settle at that amount or

any other amount.

Deferral to state PPDR processes

If HHS determines that a state law provides a process to determine the amount to be paid by

an uninsured (or self-pay) individual to a provider or facility, and that such process meets or

exceeds minimum federal requirements, HHS shall defer to the state process and direct any

PPDR requests received from uninsured (or self-pay) individuals in such state to the state

process to adjudicate the dispute resolution initiation request.

Extension of time periods for extenuating

circumstances

The time periods specified throughout the PPDR process (other than the timing of all

payments, including payment of the administrative fees) may be extended in extenuating

circumstances at HHS’s discretion if:

• An extension is necessary to address delays due to matters beyond the control of the

parties or for good cause, and

• The parties attest that prompt action will be taken to ensure that the determination under

this section is made as soon as administratively practicable under the circumstances.

Any party may request an extension by submitting a request for extension due to extenuating

circumstances through the federal IDR portal or electronic or paper mail if the extension is

necessary to address delays due to matters beyond the control of the party or for good cause.

HHS model notices

HHS has developed a model notice that SDR entities may use to provide the determination

notice to providers or facilities, and a model notice that providers or facilities may use to notify

the SDR entity and HHS that all parties agree to settle on a payment amount.

These model notices were published as part of

CMS Form Number 10791

and are available for

download.

HHS model notices (continued 1)

HHS model notices (continued 2)

Summary of the PPDR Process

Areas of particular applicability to providers and facilities have been underlined for emphasis.

Timeline Process step

Before the PPDR Process:

Within 120 calendar

days

1. Initiation Notice and Administrative Fee: the uninsured (or self-pay) individual submits the initiation notice

and other relevant information to the Secretary of the Department of Health and Human Services (HHS).

The initiation notice must be sent within 120 calendar days from when the uninsured or (self-pay) individual

received their initial bill for items and services from their provider or facility.

HHS will choose and notify the Selected Dispute Resolution Entity (SDR entity). Once HHS has chosen the

SDR entity, the uninsured (or self-pay) individual must pay an administrative fee to the SDR entity.

Within 3 business days

2. SDR Entity Conflict of Interest Identification: Should a conflict of interest exist, HHS will select a new SDR

entity to conduct the PPDR Process. If no SDR entities are available to resolve the dispute, the initially-

selected SDR entity will be required to initiate their entity-level conflict of interest mitigation plan, (which may

include identifying a sub-contractor whom they have verified does not have a conflict of interest) and submit

notice to HHS related to the implementation of the mitigation plan, no later than 3 business days following

selection by HHS. HHS will then assign the case to the identified alternative SDR entity to conduct the PPDR

process.

Summary of the PPDR Process (continued 1)

Areas of particular applicability to providers and facilities have been underlined for emphasis

(continued).

Timeline Process step

Before the PPDR Process:

Within 21 calendar

days

3. Eligibility Determination and Additional Information:

After the SDR entity receives information submitted by the uninsured or (self-pay) individual, it will notify them

regarding:

- Whether or not they are eligible for PPDR

- If additional information is needed to determine eligibility or if the patient can proceed to dispute

resolution

If additional information is required, the patient has 21 calendar days to furnish it after being notified of the

information deficiency.

PPDR Process:

4. PPDR Initiation: If the SDR entity determines that the item or service meets the eligibility criteria, and the

initiation notice contains the required information, the SDR entity will notify the uninsured (or self-pay)

individual and the provider or facility that the item or service has been determined eligible for dispute

resolution.

Summary of the PPDR Process (continued 2)

Areas of particular applicability to providers and facilities have been underlined for emphasis

(continued).

Timeline Process step

Within 3 business days

5. Parties’ Conflict of Interest Identification: The uninsured (or self-pay) individual and provider or facility

may attest to having a conflict of interest with the SDR entity. Should a conflict of interest exist, the SDR

entity must notify HHS within 3 business days of receiving the attestation. HHS will select a different entity to

conduct the PPDR process.

Within 10 business

days

6. Provider or Facility Submits Information: The provider or facility should submit any required information to

the SDR entity within 10 business days of receipt of the selection notice. This information includes:

- A copy of the good faith estimate provided to the uninsured (or self-pay) individual for the item or service

under dispute,

- A copy of the billed charges provided to the uninsured (or self-pay) individual for the item or service

under dispute,

- If available, documentation demonstrating that the difference between the billed charge and the

expected charges in the good faith estimate reflects the cost of a medically necessary item or service

and is based on unforeseen circumstances.

Summary of the PPDR Process (continued 3)

Areas of particular applicability to providers and facilities have been underlined for emphasis

(continued).

Timeline Process step

Within 3 business days

7. Patient-Provider Negotiation: If the parties to a PPDR process agree on a payment amount (through either

an offer of financial assistance or an offer of a lower amount, or an agreement by the uninsured (or self-pay)

individual to pay the billed charges in full) after the PPDR process has been initiated but before the date on

which a determination is made, the provider or facility will notify the SDR entity through the federal IDR

portal, electronically, or in paper form as soon as possible, but no later than 3 business days after the date of

the agreement.

The settlement notification must contain at a minimum, the settlement amount, the date of such settlement,

and documentation demonstrating that the provider or facility and uninsured (or self-pay) individual have

agreed to the settlement. The settlement notice must also document that the provider or facility has applied a

reduction to the uninsured (or self-pay) individual's settlement amount equal to at least half the amount of the

administrative fee paid.

Summary of the PPDR Process (continued 4)

Areas of particular applicability to providers and facilities have been underlined for emphasis

(continued).

Timeline Process step

Within 30 business

days

8. Payment Determination for PPDR by the SDR Entity: No later than 30 business days after receiving the

required information from the provider or facility, the SDR entity must make a determination regarding the

amount to be paid by the uninsured (or self-pay) individual, taking into account the requirements of the PPDR

payment determination process. The SDR entity should inform both parties of this determination as soon as

practicable after reaching a payment determination.

The determination made by the SDR entity will be binding upon the parties involved

, in the absence of fraud

or evidence of misrepresentation of facts presented to the selected SDR entity regarding the claim,

except

that the provider or facility may provide financial assistance or agree to an offer for a lower payment amount

than the SDR entity's determination

, the uninsured (or self-pay) individual may agree to pay the billed

charges in full, or the uninsured (or self-pay) individual

and the provider or facility may agree to a different

payment amount.

Time Period Extensions

Extenuating Circumstances: The parties may request extensions to most of the time periods above in

cases of extenuating circumstances.

Main Takeaways

The No Surprises Act protects uninsured (or self-pay) individuals from unexpectedly high

medical bills in two ways:

• If an individual does not have certain types of health insurance, or does not plan to use that

insurance to pay for health care items or services, they are eligible to receive a “good faith

estimate” of what they may be charged, before they receive the item or service.

• When the billed charges for any provider or facility are in excess of the good faith estimate for

that provider or facility by $400 or more, the item or service may be eligible for payment

determination by a SDR entity through the PPDR process.

A convening provider must provide a good faith estimate to the uninsured individual, including

any item or service that is reasonably expected to be provided in conjunction with a scheduled

or requested item or service by another provider or facility. A co-provider or co-facility is a

provider or facility other than a convening provider or a convening facility that furnishes items or

services that are customarily provided in conjunction with a primary item or service.

Main Takeaways (continued)

Providers’ and facilities’ main responsibilities in the PPDR process include:

• The provider or facility should submit any required information to the SDR entity within 10

business days of receipt of the selection notice.

• While the PPDR process is pending, the provider or facility must not move the bill for the

disputed item or service into collection or threaten to do so, or if the bill has already moved

into collection, the provider or facility should cease collection efforts. The provider or facility

must also suspend the accrual of any late fees on unpaid bill amounts until after the PPDR

process has concluded.

• In the event that the parties agree to settle on a payment amount, the provider or facility

should notify the SDR entity through the federal IDR Portal, electronically, or in paper form, as

soon as possible, but no later than 3 business days after the date of the agreement.

• The determination made by the SDR entity will be binding upon the parties involved.

Resources

• Requirements Related to Surprise Billing; Part II

• Patient-Provider Dispute Resolution Guidance:

https://www.cms.gov/cciio/resources/regulations-and-guidance#Patient-

Provider%20Dispute%20Resolution

• Sample Disclaimer and Model Notice: https://www.cms.gov/regulations-and-

guidancelegislationpaperworkreductionactof1995pra-listing/cms-10791

• For more information about the No Surprises Act and the PPDR process, please see

www.cms.gov/nosurprises

• For additional assistance, contact the No Surprises Help Desk at 1-800-985-3059, 8:00 am to

8:00 pm ET, 7 days a week

100

Questions

Send any questions about the provider requirements and provider

enforcement to provider_enforcement@cms.hhs.gov.

Appendix: Glossary

101

Glossary

102

Term Definition

Citation in

the CFR

Originating

No Surprises Act Rule

Authorized

Representative

An individual authorized under State law to provide consent on behalf of the uninsured (or

self-pay) individual, provided that the individual is not a provider affiliated with a facility or an

employee of a provider or facility represented in the good faith estimate, unless such

provider or employee is a family member of the uninsured (or self-pay) individual.

45 CFR

149.610(a)(

2)(i)

Requirements Related

to Surprise Billing; Part

II IFC

Billed charge The amount billed by a provider or facility for an item or service.

45 CFR

149.620(a)(

2)(i)

Requirements Related

to Surprise Billing; Part

II IFC

Convening health

care provider or

convening health

care facility

(convening provider

or convening

facility)

The provider or facility who receives the initial request for a good faith estimate from an

uninsured (or self-pay) individual and who is or, in the case of a request, would be

responsible for scheduling the primary item or service.

45 CFR

149.610(a)(

2)(ii)

Requirements Related

to Surprise Billing; Part

II IFC

Co-health care

provider or co-

health care facility

(co-provider or co-

facility)

A provider or facility other than a convening provider or a convening facility that furnishes

items or services that are customarily provided in conjunction with a primary item or service.

45 CFR

149.610(a)(

2)(iii)

Requirements Related

to Surprise Billing; Part

II IFC

Glossary (continued 1)

103

Term Definition

Citation in

the CFR

Originating

No Surprises Act Rule

Credible

information

Information that upon critical analysis is worthy of belief and is trustworthy.

45 CFR

149.620(f)

(3)(ii)

Requirements Related

to Surprise Billing; Part

II IFC

Diagnosis code

The code that describes an individual's disease, disorder, injury, or other related health

conditions using the International Classification of Diseases (ICD) code set.

45 CFR

149.610(a)(

2)(iv)

Requirements Related

to Surprise Billing; Part

II IFC

Expected charge

For an item or service, the cash pay rate or rate established by a provider or facility for an

uninsured (or self-pay) individual, reflecting any discounts for such individuals, where the

good faith estimate is being provided to an uninsured (or self-pay) individual; or the amount

the provider or facility would expect to charge if the provider or facility intended to bill a plan

or issuer directly for such item or service when the good faith estimate is being furnished to

a plan or issuer.

45 CFR

149.610(a)(

2)(v)

Requirements Related

to Surprise Billing; Part

II IFC

Good faith estimate

A notification of expected charges for a scheduled or requested item or service, including

items or services that are reasonably expected to be provided in conjunction with such

scheduled or requested item or service, provided by a convening provider, convening

facility, co-provider, or co-facility.

45 CFR

149.610(a)(

2)(vi)

Requirements Related

to Surprise Billing; Part

II IFC

Health care facility

(facility)

An institution (such as a hospital or hospital outpatient department, critical access hospital,

ambulatory surgical center, rural health center, federally qualified health center, laboratory,

or imaging center) in any State in which State or applicable local law provides for the

licensing of such an institution, that is licensed as such an institution pursuant to such law or

is approved by the agency of such State or locality responsible for licensing such institution

as meeting the standards established for such licensing.

45 CFR

149.610(a)(

2)(vii)

Requirements Related

to Surprise Billing; Part

II IFC

Glossary (continued 2)

104

Term Definition

Citation in

the CFR

Originating

No Surprises Act Rule

Health care

provider (provider)

A physician or other health care provider who is acting within the scope of practice of that

provider’s license or certification under applicable State law, including a provider of air

ambulance services.

45 CFR

149.610(a)

(2)(viii)

Requirements Related

to Surprise Billing; Part

II IFC

Items or services

All encounters, procedures, medical tests, supplies, prescription drugs, durable medical

equipment, and fees (including facility fees), provided or assessed in connection with the

provision of health care.

45 CFR

147.210(a)

(2)(xiii)

N/A

Period of care

The day or multiple days during which the good faith estimate for a scheduled or

requested item or service (or set of scheduled or requested items or services) are

furnished or are anticipated to be furnished, regardless of whether the convening provider,

convening facility, co-providers, or co-facilities are furnishing such items or services,

including the period of time during which any facility equipment and devices, telemedicine

services, imaging services, laboratory services, and preoperative and postoperative

services that would not be scheduled separately by the individual, are furnished.

45 CFR

149.610(a)

(2)(x)

Requirements Related

to Surprise Billing; Part

II IFC

Primary item or

service

The item or service to be furnished by the convening provider or convening facility that is

the initial reason for the visit.

45 CFR

149.610(a)

(2)(xi)

Requirements Related

to Surprise Billing; Part

II IFC

Service code

The code that identifies and describes an item or service using the Current Procedural

Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), Diagnosis-

Related Group (DRG) or National Drug Codes (NDC) code sets.

45 CFR

149.610(a)

(2)(xii)

Requirements Related

to Surprise Billing; Part

II IFC

Substantially in

excess

With respect to the total billed charges by a provider or facility, an amount that is at least

$400 more than the total amount of expected charges listed on the good faith estimate for

the provider or facility.

45 CFR

149.620(a)

(2)(ii)

Requirements Related

to Surprise Billing; Part

II IFC

Glossary (continued 3)

105

Term Definition

Citation in

the CFR

Originating

No Surprises Act Rule

Total billed

charge(s)

The total of billed charges, by a provider or facility, for all primary items or services and all

other items or services furnished in conjunction with the primary items or services to an

uninsured (or self-pay) individual, regardless of whether such items or services were

included in the good faith estimate.

45 CFR

149.620(a)

(2)(iii)

Requirements Related

to Surprise Billing; Part

II IFC

Uninsured (or self-

pay) individual

(A) An individual who does not have benefits for an item or service under a group healt

an, group or individual health insurance coverage offered by a health insurance issuer,

Federal health care program (as defined in section 1128B(f) of the Social Security Act), or

a health benefits plan under chapter 89 of title 5, United States Code; or

(B) An individual who has benefits for such item or service under a group health plan, or

individual or group health insurance coverage offered by a health insurance issuer, or

health benefits plan under chapter 89 of title 5, United States Code but who does not seek

to have a claim for such item or service submitted to such plan or coverage.

45 CFR

149.610(a

)(2)(xiii)

Requirements Related

to Surprise Billing; Part

II IFC