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CMS Announces New Information about No Surprises Act IDR Process and Good Faith Estimate

CMS guidance for No Surprises Act

The Centers for Medicare and Medicaid Services (CMS) published new guidance that provides important clarifications about the content of Good Faith Estimates required by the No Surprises Act (NSA). In addition, CMS also issued a new FAQ document that summarizes the entire NSA.

IDR Portal to Launch Week Of April 11th

Notably, the announcement also said that CMS would launch the Federal Independent Dispute Resolution (IDR) portal the week of April 11th. The Federal IDR portal is an essential part of the NSA's IDR process for resolving out-of-network (OON) reimbursement disputes between providers and health plans in “surprise” scenarios covered under the NSA.

To initiate IDR, providers must notify both the health plan and the federal government. The Federal IDR portal is the only way to send this notification to the federal government. However, providers have been unable to initiate IDR cases against health plans since the NSA took effect on January 1st because the Federal IDR portal was not launched.

Many claims that would have been eligible for IDR had the portal live has since exceeded the time limit for filing these cases. CMS said in previous guidance that it would allow providers 15 business days after the IDR portal is launched to submit claims to the IDR portal.

HBMA members should advise their clients with IDR-eligible claims to prepare to submit them within this timeframe.

Contents of the GFE

The NSA requires all providers to furnish uninsured or self-pay patients (insured patients who do not want to submit the claim to their insurance) with a good faith estimate (GFE) for care upon request or scheduling care. The GFE must include an estimate for items and services reasonably expected to be furnished during that visit.

GFEs must always include treatment codes. GFEs must also include diagnosis codes only where one is required to calculate the GFE. In many cases, the provider has no way of knowing what care for the patient’s diagnosis until they examine the patient.

CMS clarifies that GFEs do not need to include diagnosis codes if the provider does not know the patient’s diagnosis when they schedule care.

The guidance also addresses other questions about GFEs, such as recurring services and unexpected items or services.

 

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