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jbell on DSKJLSW7X2PROD with RULES2

Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations the year in which the item or service is furnished.
B If the Centers for Medicare &
Medicaid Services has not established a Medicare payment rate for the item or service billed under the new service code, the plan or issuer must calculate the qualifying payment amount by first calculating the ratio of the rate that the plan or issuer reimburses for the item or service billed under the new service code compared to the rate that the plan or issuer reimburses for the item or service billed under the related service code, and then multiplying the ratio by the qualifying payment amount for an item or service billed under the related service code.
ii For an item or service furnished in a subsequent year before the first sufficient information year for such item or service with respect to such plan or coverage or before the first year for which an eligible database has sufficient information to a calculate a rate under paragraph c3i of this section in the immediately preceding year, the plan or issuer must calculate the qualifying payment amount by increasing the qualifying payment amount determined under paragraph c4i of this section or this paragraph c4ii, as applicable, for such item or service for the year immediately preceding such subsequent year, by the percentage increase in CPI
U over such preceding year;
iii For an item or service furnished in the first sufficient information year for such item or service with respect to such plan or coverage or the first year for which an eligible database has sufficient information to calculate a rate under paragraph c3i of this section in the immediately preceding year, the plan or issuer must calculate the qualifying payment amount in accordance with paragraph c3 of this section.
d Information to be shared about qualifying payment amount. In cases in which the recognized amount with respect to an item or service furnished by a nonparticipating provider, nonparticipating emergency facility, or nonparticipating provider of air ambulance services is the qualifying payment amount, the plan or issuer must provide in writing, in paper or electronic form, to the provider or facility, as applicable 1 With each initial payment or notice of denial of payment under 2590.7164, 2590.7165, or 2590.7171 of this part:
i The qualifying payment amount for each item or service involved;
ii A statement to certify that, based on the determination of the plan or issuer
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A The qualifying payment amount applies for purposes of the recognized amount or, in the case of air ambulance services, for calculating the participants or beneficiarys cost sharing; and B Each qualifying payment amount shared with the provider or facility was determined in compliance with this section;
iii A statement that if the provider or facility, as applicable, wishes to initiate a 30-day open negotiation period for purposes of determining the amount of total payment, the provider or facility may contact the appropriate person or office to initiate open negotiation, and that if the 30-day negotiation period does not result in a determination, generally, the provider or facility may initiate the independent dispute resolution process within 4 days after the end of the open negotiation period; and iv Contact information, including a telephone number and email address, for the appropriate person or office to initiate open negotiations for purposes of determining an amount of payment including cost sharing for such item or service.
2 In a timely manner upon request of the provider or facility:
i Information about whether the qualifying payment amount for items and services involved included contracted rates that were not on a feefor-service basis for those specific items and services and whether the qualifying payment amount for those items and services was determined using underlying fee schedule rates or a derived amount;
ii If a plan or issuer uses an eligible database under paragraph c3 of this section to determine the qualifying payment amount, information to identify which database was used; and iii If a related service code was used to determine the qualifying payment amount for an item or service billed under a new service code under paragraph c4i or ii of this section, information to identify the related service code;
iv If applicable, a statement that the plans or issuers contracted rates include risk-sharing, bonus, penalty, or other incentive-based or retrospective payments or payment adjustments for the items and services involved as applicable that were excluded for purposes of calculating the qualifying payment amount.
e Certain access fees to databases. In the case of a plan or issuer that, pursuant to this section, uses an eligible database to determine the qualifying payment amount for an item or service, the plan or issuer is responsible for any
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costs associated with accessing such database.
f Applicability date. The provisions of this section are applicable with respect to plan years beginning on or after January 1, 2022.
2590.7167 Complaints process for surprise medical bills regarding group health plans and group health insurance coverage.

a Scope and definitions1 Scope.
This section establishes a process to receive and resolve complaints regarding information that a specific group health plan or health insurance issuer offering group health insurance coverage may be failing to meet the requirements under subpart D of this part, which may warrant an investigation.
2 Definitions. In this section i Complaint means a communication, written or oral, that indicates there has been a potential violation of the requirements under subpart D of this part, whether or not a violation actually occurred.
ii Complainant means any individual, or their authorized representative, who files a complaint as defined in paragraph a2i of this section.
b Complaints process. 1 DOL will consider the date a complaint is filed to be the date upon which DOL receives an oral or written statement that identifies information about the complaint sufficient to identify the parties involved and the action or inaction complained of.
2 DOL will notify complainants, by oral or written means, of receipt of the complaint no later than 60 business days after the complaint is received.
DOL will include a response acknowledging receipt of the complaint, notifying the complainant of their rights and obligations under the complaints process, and describing the next steps of the complaint resolution process. As part of the response, DOL may request additional information needed to process the complaint. Such additional information may include:
i Explanations of benefits;
ii Processed claims;
iii Information about the health care provider, facility, or provider of air ambulance services involved;
iv Information about the group health plan or health insurance issuer covering the individual;
v Information to support a determination regarding whether the service was an emergency service or non-emergency service;
vi The summary plan description, policy, certificate, contract of insurance,
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