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Federal Register / Vol. 86, No. 192 / Thursday, October 7, 2021 / Rules and Regulations
2 Process to request an extension.
The parties may request an extension by submitting a request for extension due to extenuating circumstances through the Federal IDR portal if the extension is necessary to address delays due to matters beyond the control of the parties or for good cause.
h Applicability date. The provisions of this section are applicable with respect to plan years in the individual market, policy years beginning on or after January 1, 2022, except that the provisions regarding IDR entity certification at paragraphs a and e of this section are applicable beginning on October 7, 2021.

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149.520 Independent dispute resolution process for air ambulance services.

a Definitions. Unless otherwise stated, the definitions in 149.30 apply.
b Determination of out-of-network rates to be paid by health plans and health insurance issuers; independent dispute resolution process1 In general. Except as provided in paragraphs b2 and 3 of this section, in determining the out-of-network rate to be paid by group health plans and health insurance issuers offering group or individual health insurance coverage for out-of-network air ambulance services, plans and issuers must comply with the requirements of 149.510, except that references in 149.510 to the additional circumstances in 149.510c4iiiC shall be understood to refer to paragraph b2
of this section.
2 Additional information.
Additional information submitted by a party, provided the information is credible, relates to the circumstances described in paragraphs b2i through vi of this section, with respect to a qualified IDR service of a nonparticipating provider of air ambulance services or health insurance issuer of group or individual health insurance coverage that is the subject of a payment determination. This information must also clearly demonstrate that the qualifying payment amount is materially different from the appropriate out-of-network rate.
i The quality and outcomes measurements of the provider that furnished the services.
ii The acuity of the condition of the participant, beneficiary, or enrollee receiving the service, or the complexity of furnishing the service to the participant, beneficiary, or enrollee.
iii The training, experience, and quality of the medical personnel that furnished the air ambulance services.

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iv Ambulance vehicle type, including the clinical capability level of the vehicle.
v Population density of the point of pick-up as defined in 42 CFR 414.605
for the air ambulance such as urban, suburban, rural, or frontier.
vi Demonstrations of good faith efforts or lack thereof made by the nonparticipating provider of air ambulance services or the plan or issuer to enter into network agreements with each other and, if applicable, contracted rates between the provider of air ambulance services and the plan or issuer, as applicable, during the previous 4 plan years.
3 Reporting of information relating to the IDR process. In applying the requirements of 149.510f, within 30
business days of the close of each month, for services furnished on or after January 1, 2022, the information the certified IDR entity must report, in a form and manner specified by the Secretary, with respect to the Federal IDR process involving air ambulance services is:
i The number of notices of IDR
initiation submitted under the Federal IDR process to the certified IDR entity that pertain to air ambulance services during the immediately preceding month;
ii The number of such notices of IDR
initiation with respect to which a final determination was made under 149.510c4ii as applied by paragraph b1 of this section;
iii The number of times the payment amount determined or agreed to under this subsection has exceeded the qualifying payment amount, specified by services;
iv With respect to each notice of IDR
initiation under 149.510b2 of this part as applied by paragraph b1 of this section for which a determination was made, the following information:
A A description of each air ambulance service included in such notification, including the relevant billing and service codes;
B The point of pick-up as defined in 42 CFR 414.605 for the services included in such notification;
C The amount of the offers submitted under 149.510c4i as applied by paragraph b1 of this section by the group health plan or health insurance issuer as applicable and by the nonparticipating provider of air ambulance services, expressed as a dollar amount and as a percentage of the qualifying payment amount;
D Whether the offer selected by the certified IDR entity under 149.510c4ii as applied by paragraph b1 of this section to be the
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payment amount applied was the offer submitted by the plan or issuer as applicable or by the provider of air ambulance services;
E The amount of the selected offer expressed as a dollar amount and as a percentage of the qualifying payment amount;
F The rationale for the certified IDR
entitys decision, including the extent to which the decision relied on the criteria in paragraph b2 of this section;
G Air ambulance vehicle type, including the clinical capability level of such vehicle to the extent this information has been provided to the certified IDR entity;
H The identity for each plan or issuer and provider of air ambulance services, with respect to the notification.
Specifically, each certified IDR entity must provide each partys name and address, as applicable; and I For each determination, the number of business days elapsed between selection of the certified IDR
entity and the selection of the payment amount by the certified IDR entity.
v The total amount of certified IDR
entity fees paid to the certified IDR
entity under paragraph 149.510d1
as applied by paragraph b1 of this section during the month for determinations involving air ambulance services.
c Applicability date. The provisions of this section are applicable with respect to plan years in the individual market, policy years beginning on or after January 1, 2022.
21. Subpart G, consisting of 149.610 and 149.620, is added to read as follows:
Subpart GProtection of Uninsured or Self-Pay Individuals 149.610 Requirements for provision of good faith estimates of expected charges for uninsured or self-pay individuals.

a Scope and definitions1 Scope.
This section sets forth requirements for health care providers and health care facilities related to the issuance of good faith estimates of expected charges for uninsured or self-pay individuals or their authorized representatives, upon request or upon scheduling an item or service.
2 Definitions. For purposes of this section, the following definitions apply:
i Authorized representative means an individual authorized under State law to provide consent on behalf of the uninsured or self-pay individual, provided that the individual is not a provider affiliated with a facility or an employee of a provider or facility represented in the good faith estimate,
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