CurrentMedicarePolicy N/A

Patient-Provider Dispute Resolution (PPDR) Administrative Fee under the No Surprises Act

Governs the administrative fee for the Patient-Provider Dispute Resolution (PPDR) process under the No Surprises Act for uninsured (or self-pay) individuals and providers/facilities; announces the fee amount and outlines payment and settlement procedures.

Policy Summary

PayerMedicare

PolicyPPDR administrative fee policy (No Surprises Act)

Policy CodePolicy N/A

Change TypeOperational/administrative

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionUninsured individuals must submit an initiation notice to HHS and pay the PPDR administrative fee to the assigned SDR entity to initiate a dispute.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$25Administrative fee for calendar year 2023 to initiate a PPDR case

$400Minimum excess amount over good faith estimate to be eligible for PPDR

Jan 1, 2022PPDR process effective date for good faith estimates

3 daysDeadline for provider/facility to notify SDR of a settlement

PPDR Administrative Fee Criteria & Effects

PPDR administrative fee criteria and effects

Conditions and effects related to payment of the PPDR administrative fee:

An uninsured (or self-pay) individual may initiate PPDR when billed charges exceed the good faith estimate by at least $400.

The initiating uninsured (or self-pay) individual must pay an administrative fee to the Selected Dispute Resolution (SDR) entity to participate in the PPDR process; for calendar year 2023 the fee is $25.

The SDR entity must remit all administrative fees collected to the Secretary of HHS upon receiving an invoice.

If the uninsured (or self-pay) individual prevails in the dispute resolution, the SDR entity will apply a reduction equal to the administrative fee paid by the individual to the amount the individual must pay the provider or facility.

Policy Summary

PayerMedicare

PolicyPPDR administrative fee policy (No Surprises Act)

Policy CodePolicy N/A

Change TypeOperational/administrative

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionUninsured individuals must submit an initiation notice to HHS and pay the PPDR administrative fee to the assigned SDR entity to initiate a dispute.

SourceLink

On This Page

Provider / Facility Responsibilities and Settlement

Billing Rule

Provider settlement notification

Providers and facilities must notify the Selected Dispute Resolution (SDR) entity promptly if the parties reach a settlement prior to a formal determination. Notify via the online Federal IDR portal, electronically, or by paper no later than 3 business days after the agreement date. If using paper, documentation must be postmarked within 3 business days. The settlement notice must confirm that the provider or facility applied a reduction to the uninsured (or self-pay) individual's settlement amount equal to at least half of the administrative fee. Upon receipt, the SDR entity will close the PPDR case as settled and the agreed payment amount will apply. Any administrative fees collected by the SDR entity but not yet remitted to HHS at case closure must be remitted to the Secretary of HHS upon receiving an invoice from HHS.

Notify SDR within 3 business days of agreement (or postmark within 3 business days for paper submissions).
Settlement notice must document reduction >= 50% of the administrative fee applied to the uninsured/self-pay individual's amount.
SDR will close the PPDR case as settled upon receipt of notice.
Any unremitted administrative fees collected by SDR at case closure must be remitted to HHS upon invoice.

Note

Initiation and fee payment by individual

If an uninsured (or self-pay) individual initiates PPDR and pays the administrative fee, providers should expect the SDR entity to apply the fee rules described by HHS: when the individual prevails, the SDR will reduce the individual's payment obligation by the administrative fee amount; when the provider or facility prevails, no reduction will be applied. The SDR entity remits all administrative fees collected to the Secretary of HHS upon receiving an invoice from HHS.

Administrative fee may be paid electronically or by mail to the SDR once assigned by HHS.
If the individual prevails, SDR applies reduction equal to the administrative fee to the individual's payment to the provider/facility.
If the provider/facility prevails, no reduction for the administrative fee is applied.

Key Definitions

Uninsured (or self-pay) individual

Definition (term)Uninsured (or self-pay) individual

Definition (text)An individual who does not have health benefits for an item or service under group or individual health coverage or a federal health care program, or who has such benefits but does not seek to have a claim submitted to such coverage.

ContextThis definition applies for determining who may initiate the PPDR process and who must receive a good faith estimate.

Selected Dispute Resolution (SDR) entity

Definition (term)Selected Dispute Resolution (SDR) entity

Definition (text)The entity assigned by the Secretary of HHS to administer PPDR cases and collect administrative fees.

Primary responsibilitiesReceive initiation fees from individuals, administer PPDR cases, apply fee reductions when the individual prevails, and remit collected fees to the Secretary of HHS upon invoice.

OpenPayer

Patient-Provider Dispute Resolution (PPDR) Administrative Fee under the No Surprises Act

PPDR Administrative Fee Criteria & Effects

Coding and Eligibility Thresholds

Provider / Facility Responsibilities and Settlement

Key Definitions