AEOB request submission

Participating providers must submit AEOB requests via the PEAR Portal; non‑participating providers must submit AEOB requests via customer service. Delivery to the member will follow the member's preference (paper or electronic) and members may also access the AEOB request tool via ibx.com.

• Delivery mode (paper or electronic) based on member preference
• AEOB request tool available to members at ibx.com

Prior authorization prerequisites and continuity notices shown in tool

The cost-comparison tool will display required prerequisites, prior‑authorization disclaimers, and messaging about out‑of‑network balance billing; Independence will comply with statutory delivery timing and member preferences for paper responses.

• Tool displays required prerequisites and disclaimers
• Tool displays required messaging concerning OON services and balance billing
• Paper responses delivered per member preference and legal requirements

Continuity of care requests require Medical Director review

Members may request continuity of care when a network provider leaves; requests are subject to Medical Director review and determinations are made based on medical necessity. Up to 90 calendar days of continuity at in‑network cost‑sharing is offered for active treatment of acute conditions or the acute phase of chronic conditions.

• Independence notifies members when a network provider leaves
• Continuity requests reviewed by Medical Director and based on medical necessity
• Up to 90 calendar days of in‑network cost‑sharing for eligible cases

Claims processed per CAA protections (balance‑billing prohibited)

Independence updated claims processing to recognize CAA‑defined claim types and will process out‑of‑network claims that are protected by the CAA in accordance with the statute and regulatory guidance; members and providers will be informed that such claims are subject to the CAA and balance billing is prohibited.

• Claims processed according to CAA definitions and guidance
• Members/providers informed that balance billing is prohibited for these claims
• Recognized amount calculations completed per CAA requirements

Provider negotiation requests handled by Independence (no customer notice)

Independence will negotiate with providers and handle provider‑initiated payment negotiations without notifying customers; if negotiation results in an agreed payment the claim will be adjusted to that amount.

• Customers will not be notified of provider-requested negotiations
• Successful negotiations result in claim adjustment to agreed amount

Independence negotiates and pursues IDR on customer's behalf (no notice)

Independence will negotiate on the customer's behalf and respond to provider‑initiated IDR without notifying the customer; claim adjustments will reflect the outcome of negotiations or IDR.

• Independence negotiates with providers on customer's behalf
• Customers will not receive notice while negotiations or IDR are underway
• Claims adjusted based on IDR entity determinations

IDR process timelines and provider initiation requirements

IDR timelines must follow the federal schedule: a 30‑business‑day open negotiation period starting on the day of initial payment or denial; if negotiation fails the provider may initiate IDR within 4 business days; mutual selection of an IDR entity within 3 business days (or departments select within 6 business days); submit payment offers within 10 business days after entity selection; IDR entity issues a determination within 30 business days; payment submitted within 30 business days after determination.

• 30 business days: open negotiation period (starts on date of initial payment or denial)
• 4 business days: provider may initiate IDR after negotiation ends
• 3 business days: mutual agreement on IDR entity selection
• 6 business days: departments select entity if no agreement
• 10 business days: submit payment offers after entity selection
• 30 business days: IDR entity issues payment determination
• 30 business days: submit payment after determination

Provide Form 5500 Plan Code, employee contribution, and PBM via Employer Portal

For the June 1, 2024 RxDC submission and subsequent filings, Independence will collect the Form 5500 Plan Code, employee contribution information, and the PBM name through the Employer Portal; the Form 5500 Plan Code must be submitted via the portal by early 2024.

• Form 5500 Plan Code collected via Employer Portal
• Employee contribution and PBM name collected via Employer Portal
• Due date for portal submission: early 2024 (for June 1, 2024 filing)

Independence submits P2/D1/D2; Optum Rx supplies D3–D8 when applicable

Independence will produce and submit P2, D1, and D2 files for self‑funded customers; if Optum Rx is the PBM, Optum Rx will provide D3–D8 to Independence and those files will be included in the submission package. For customers using a different PBM, D3–D8 will not be included.

• Independence submits P2, D1, D2 for self‑funded customers
• Optum Rx provides D3–D8 when Optum Rx is the PBM; Independence includes them
• No D3–D8 when pharmacy is carved out to other PBMs

Customers need not act and will not be notified for RxDC submissions

Customers are not required to make decisions for RxDC submission; Independence will not notify plan sponsors after submission and CMS provides no mechanism for employers to verify third‑party submissions.

• No customer action required for RxDC submission
• Independence will not inform plan sponsors when data is submitted
• CMS provides no mechanism for employers to verify submissions by others

No ASA amendment required—existing agreements require compliance with law

An amendment to Independence's ASAs is not required for self‑funded pharmacy and medical administrative services because existing agreements include compliance‑with‑law provisions; similarly, no amendment is necessary for insured medical agreements.

• ASAs already require compliance with applicable law including CAA and TCR
• No separate ASA amendment required solely for RxDC or related reporting

Independence files Gag Clause attestation unless self‑funded group timely opts out

Independence will submit the Gag Clause attestation for insured and self‑funded customers by the required CMS date; self‑funded groups may opt out by notifying the Claims Administrator by November 15, 2023, otherwise Independence will submit on their behalf. Independence will not submit attestations for customers not active in December of the attestation year and cannot file attestations for pharmacy or behavioral health contracts carved out to other vendors.

• Independence submits attestation for insured groups (covers Dec 27, 2020 through submission)
• Self‑funded groups must opt out by Nov 15, 2023 to file themselves
• Attestations not filed for customers not active in December of attestation year
• Cannot file attestations for carved‑out Pharmacy or Behavioral Health contracts

Provider contracts contain no gag‑clause prohibitions on disclosure

Independence confirms that provider contracts do not contain gag clauses that prohibit disclosure of provider‑specific cost or quality information.

• Provider contracts do not contain gag clauses prohibiting disclosure

Independence produces MRFs and offers cost estimator tool to self‑funded customers

Independence will implement TCR responsibilities for insured plans and will produce machine‑readable files on behalf of self‑funded customers unless otherwise notified; the Independence cost estimator tool is available to self‑funded customers that utilize it.

• Independence produces MRFs for insured plans and on behalf of self‑funded customers unless notified
• Cost‑estimator tool available to self‑funded customers that use it

Member‑level data and accumulator info provided for an additional charge

Member‑level accumulator information and other requested data elements will be provided only for an additional charge; standard TCR/CAA transparency tools are available at no additional cost.

• Member‑level accumulator and similar data provided at additional charge
• Standard transparency tools required by TCR/CAA provided at no cost

Exclude non‑contracting vendor networks from MRFs

Vendors that are not contracting providers (i.e., non‑contracting vendor networks) will not be included in Independence's machine‑readable files.

• Only rates from Independence's contracting providers are included in MRFs
• Non‑contracting vendors are excluded

Publish customer‑specific MRF links (public URLs to ToC and JSON files)

Independence will provide customer‑specific public URLs that link to an MRF Table of Contents and to plan‑specific in‑network and out‑of‑network JSON files; self‑funded customers will receive monthly email notifications with their URLs.

• Customer‑specific public link pattern provided (example URLs shown)
• Links point to customer ToC and plan‑specific .json MRF files
• Monthly email sent to self‑funded customer's mandate email address when files are ready

Allow plan sponsors to share Independence MRF links with third parties (data agreements required)

Plan sponsors may share the Independence‑supplied MRF URL with third‑party vendors; Independence will share necessary data and support MRF access subject to appropriate data agreements and standard monthly updates.

• MRFs are publicly accessible with no account required
• Plan sponsors may provide their Independence link to vendors
• Data sharing subject to appropriate data agreements; updates occur monthly