CurrentMedicarePolicy N/A

Calendar Year 2022 Fee Guidance for the Federal Independent Dispute Resolution (IDR) Process under the No Surprises Act

Guidance establishing the calendar year 2022 administrative fee for parties participating in the Federal IDR process and the allowable ranges for certified IDR entity fees for single and batched determinations; applies where specified state law or All-Payer Model Agreements do not apply.

Policy Summary

PayerMedicare

PolicyCalendar Year 2022 Fee Guidance for the Federal IDR Process under the No Surprises Act

Policy CodePolicy N/A

Change TypeTechnical guidanceno material coverage changes

Effective DateJan 1, 2022

Next Review DateN/A

Key ActionEach party must pay a $50 administrative fee when the certified IDR entity is selected; parties also pay the certified IDR entity fee with the non‑prevailing party ultimately responsible.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$50administrative fee per party for 2022

$200-$500certified IDR fee range (single)

$268-$670certified IDR fee range (batched)

≈17,333annual claims (nonparticipating providers/facilities)

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Fee criteria and processes (2022)

Fee and approval criteria for calendar year 2022:

Administrative fee of $50 is due from each party participating in the Federal IDR process for calendar year 2022.

Certified IDR entities must charge a fixed certified IDR entity fee for single determinations within the range of $200-$500 for calendar year 2022, unless otherwise approved by the Departments.

If a certified IDR entity elects a different fixed fee for batched determinations, that fee must be within the range of $268-$670 for calendar year 2022, unless otherwise approved by the Departments.

Certified IDR entities may not charge fees beyond the Department-set upper or lower bounds unless they obtain written approval from the Departments.

To request approval to charge a fee outside the permitted range, an IDR entity (at certification or annually thereafter) must submit a written proposal through the Federal IDR portal that includes: (1) the proposed alternative fixed fee; (2) a description of circumstances requiring the alternative fee (for example, cost analysis, historical and anticipated volume, staffing and resource needs, impact of inflation, market and geographic variations, and consistency of fees over time); and (3) other supporting justification as described in the guidance.

Departments will provide written approval or denial of requests to charge fees outside the stated ranges; entities approved to charge outside the ranges generally will not be randomly selected by the Departments unless there are insufficient entities charging within range available.

Certified IDR entities may not bill additional incidental or processing fees beyond the approved certified IDR entity fee and the administrative fee; incidental costs must be included within the certified IDR entity fee.

Fee rates, ranges, and exceptions (2022)

Fee rates (2022)mixed

	Fixed certified IDR entity fee range for single determinations: $200-$500 (2022)
	Fixed certified IDR entity fee range for batched determinations: $268-$670 (2022)
	Administrative fee per party for Federal IDR process: $50 (2022)

Fee range exception process

Submission methodSubmit a written proposal through the Federal IDR portal requesting approval to charge outside the Departments' fee ranges.

Required proposed feeInclude the alternative fixed fee the IDR entity proposes to charge (specify single and/or batched determination fee).

Justification elementsProvide a description of circumstances requiring the alternative fee, such as cost analysis of historical and anticipated volume, time/resources, personnel, compliance costs, inflation, market and geographic variations, and fee consistency over time.

Timing for requestRequest may be made at the time of certification or annually thereafter (IDR entities may update fees and seek approval each year).

Departments' responseDepartments will review the written proposal and must provide written approval for an IDR entity to charge fees beyond the published upper or lower limits.

Payment responsibilities and requests to exceed fee ranges

Billing Rule

Payment responsibilities and timing for administrative and certified IDR entity fees

Each party to an IDR payment determination must pay the administrative fee at the time the certified IDR entity is selected; parties also pay a certified IDR entity fee when submitting an offer, with the non‑prevailing party ultimately responsible for the certified IDR entity fee. The certified IDR entity fee paid by the prevailing party will be returned to that party at the conclusion of the process. For batched claims, the party with the fewest determinations in its favor is considered the non‑prevailing party and is responsible for the certified IDR entity fee; if each party prevails equally, the fee will be split evenly. If the parties settle before a determination, the fee will be split evenly unless they agree otherwise.

Administrative fee is paid by each party to the certified IDR entity and remitted to the Departments at the time the certified IDR entity is selected.
Each party pays a certified IDR entity fee when submitting an offer; the non‑prevailing party ultimately bears that fee.
Certified IDR entity returns the certified IDR entity fee paid by the prevailing party at conclusion of the process.
In batched determinations, the party with fewer favorable determinations is the non‑prevailing party and pays the fee; ties split the fee evenly; pre‑determination settlements split the fee evenly unless agreed otherwise.

Key terms

Federal IDR process

DefinitionThe Federal Independent Dispute Resolution (IDR) process is the federal procedure established under the No Surprises Act for resolving out-of-network payment disputes when specified state law or All-Payer Model Agreements do not apply.

ScopeAvailable to nonparticipating facilities, nonparticipating providers, plans, and issuers to determine out-of-network rates for emergency services, certain items and services at in-network facilities, and air ambulance services as specified.

Authority and implementing rulesEstablished under Code section 9816/9817, ERISA sections 716/717, and PHS Act sections 2799A-1/2799A-2 and implemented via the Requirements Related to Surprise Billing; Part II interim final rules.

Administrative fee (per party)

What it isA per-party administrative fee paid to the Departments when a certified IDR entity is selected to participate in the Federal IDR process.

Prior Authorization

Request to charge fees outside the Departments' fee ranges

IDR entities seeking to charge a certified IDR entity fee outside the Departments' established upper or lower bounds must submit a written proposal through the Federal IDR portal that includes the proposed alternative fixed fee, a description of the circumstances requiring the alternative fee (for example, a cost analysis addressing historical/anticipated volume, time and resources, staffing, and effects of inflation or geographic variation), and a description of how the alternative fee will mitigate those circumstances. The Departments will issue written approval or denial.

Submit a written proposal via the Federal IDR portal (https://www.nsa-idr.cms.gov) at certification or annually thereafter.
Include: (1) the alternative fixed fee proposed; (2) description/justification (e.g., cost analysis, staffing, compliance costs, volume projections, inflation/market/geographic impacts); (3) description of mitigation using the alternative fee.
Departments will review and provide written approval or denial; entities approved to charge outside ranges generally will not be randomly selected unless insufficient in-range entities are available.