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lotter on DSK11XQN23PROD with RULES2

Federal Register / Vol. 86, No. 192 / Thursday, October 7, 2021 / Rules and Regulations should account for any discounts offered by the provider or facility.
B For an item or service that does not appear on the good faith estimate new item or service:
1 If the SDR entity determines that the information submitted by the provider or facility does not provide credible information that the billed charge for the new item or service 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.
2 If the SDR entity determines that the information submitted by the provider or facility provides credible information that the billed charge for the new item or service 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 select as the amount to be paid for the new item or service, the lesser of:
i The billed charge; or ii 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 149.140a7 where the services were provided, that is reflected in an independent database as defined in 149.140a3 using the methodology described in 149.140c3. 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.
C To calculate the final payment determination amount, the SDR entity must add together the amounts to be paid for all items or services subject to the determination. In cases where the final amount determined by the SDR
entity is lower than the billed charges, the SDR entity must reduce the total amount determined by the amount paid by the individual for the administrative fee described in paragraph g of this section to calculate the final payment determination amount to be paid by the individual for the items or services.
Once the final payment determination amount has been calculated, the SDR
entity will inform the uninsured or selfpay individual and the provider or facility, through the Federal IDR portal, or by electronic or paper mail, of such determination, the determination
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amount and the SDR entitys justification for making the determination. After such notification is made, the SDR entity will close the case.
4 Effects of determination. A
determination made by an SDR entity under this paragraph f will be binding upon the parties involved, in the absence of a 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 entitys determination, the uninsured or selfpay 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.
g Costs of patient-provider dispute resolution process1 Administrative fee to participate in the patient-provider dispute resolution process. i The uninsured or self-pay individual shall pay to the SDR entity the administrative fee amount described in section g2 of this section at the initiation of the patient-provider dispute resolution process described in paragraph c of this section. The SDR entity shall remit all administrative fees collected to the Secretary upon receiving an invoice from HHS.
ii In cases where the SDR entity issues a determination and the provider or facility is the non-prevailing party as described in section g1iv of this section, the provider or facility must pay an amount equal to the administrative fee to the uninsured or self-pay individual in the form of a reduction in the payment amount that is applied by the SDR entity to the final payment determination amount as described in paragraph f3 of this section.
iii If the SDR entity issues a determination and the provider or facility is the prevailing party as described in paragraph g1iv of this section, the provider or facility is not required to pay an amount equal to the administrative fee to the uninsured or self-pay individual in the form of a reduction in the payment amount that is applied by the SDR entity to the final payment determination amount as described in paragraph f3 of this section.
iv For purposes of paragraphs g1ii and iii of this section, the prevailing party is the provider or facility in cases where the SDR entity determines the amount to be paid as equal to the billed charges; and the prevailing party is the uninsured or self-pay individual in cases where the
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SDR entity determines the-amount to be paid as less than the billed charges.
v Allocation of administrative fee in the case of settlement. In case of a settlement described in paragraph f1
of this section, the provider or facility must pay an amount equal to half of the administrative fee to the uninsured or self-pay individual in the form of a reduction in the payment amount that is applied to the final settlement amount.
The provider or facility will document in the settlement notice described in paragraph f1 that it has applied a payment reduction of at least half of the administrative fee amount to the uninsured or self-pay individuals settlement amount.
2 Establishment of the administrative fee. The amount of the administrative fee described in paragraph g1 of this section will be specified by the Secretary through guidance.
h Deferral to State patient-provider dispute resolution processes1 In general. If the Secretary 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 the requirements in paragraph h2 of this section, the Secretary shall defer to the State process and direct any patientprovider dispute resolution requests received from uninsured or self-pay individuals in such state to the State process to adjudicate the dispute resolution initiation request.
2 Minimum Federal requirements. A
State process described in paragraph h1 of this section shall at a minimum:
i Be binding, unless the provider or facility offer for the uninsured or selfpay individual to pay a lower payment amount than the determination amount;
ii Take into consideration a good faith estimate, that meets the minimum standards established in 149.160, provided by the provider or facility to the uninsured or self-pay individual;
iii If the State has a fee charged to uninsured or self-pay individuals to participate in the patient-provider dispute resolution process, the fee must be equal to or less than the Federal administrative fee-established in paragraph g of this section; and iv Have in place conflict-of-interest standards that at a minimum meets the requirements set forth in paragraphs d and e of this section.
3 HHS determination of State process. HHS will review the State process to determine whether it meets or exceeds the minimum Federal requirements set forth in paragraph
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