Voglio sapere a riguardo di…

lotter on DSK11XQN23PROD with RULES2

56140

Federal Register / Vol. 86, No. 192 / Thursday, October 7, 2021 / Rules and Regulations
iii An affiliate or subsidiary of a professional or trade association representing a provider or facility; or iv An SDR entity, or any personnel assigned to a determination has a material familial, financial, or professional relationship with a party to the payment determination being disputed, or with any officer, director, or management employee of the provider, the providers group or practice association, or the facility that is a party to the dispute.
4 Either party to the dispute resolution process the uninsured or self-pay individual, or the provider or facility may attest that a conflict of interest exists in relation to the SDR
entity assigned to a payment dispute, in which case the SDR entity must notify the Secretary of HHS no later than 3
business days receiving the attestation.
f Payment determination for PatientProvider dispute resolution1
Determination of payment amount through settlementi In general. If the parties to a dispute resolution process agree on a payment amount through either an offer of financial assistance or an offer of a lower amount, or an agreement by the uninsured or self-pay individual to pay the billed charges in full after the dispute resolution process has been initiated but before the date on which a determination is made under paragraph f3 of this section, the provider or facility will notify the SDR
entity through the Federal IDR Portal, electronically, or in paper form as soon as possible, but no later than 3 business days after the date of the agreement. The settlement notification must contain at a minimum, the settlement amount, the date of such settlement, and documentation demonstrating that the provider or facility and uninsured or self-pay individual have agreed to the settlement. The settlement notice must also document that the provider or facility has applied a reduction to the uninsured or self-pay individuals settlement amount equal to at least half the amount of the administrative fee paid as set forth in paragraph g of this section. Once the SDR entity receives the settlement notice, the SDR entity shall close the dispute resolution case as settled and the agreed upon payment amount will apply for the items or services.
ii Treatment of payments made prior to determination. Payment of the billed charges or a portion of the billed charges by the uninsured or self-pay individual or by another party on behalf of the uninsured or self-pay individual prior to a determination under paragraph f3 of this section does not demonstrate agreement by the
VerDate Sep<11>2014

22:02 Oct 06, 2021

Jkt 256001

uninsured or self-pay individual to settle at that amount or any other amount.
2 Determination of payment amount through the patient-provider dispute resolution processi In general. With respect to an item or service to which an agreement described in paragraph f1 of this section does not apply, not later than 10 business days after the receipt of the selection notice from the SDR entity described in paragraph c4i of this section, the provider or facility must submit to the SDR entity:
A A copy of the good faith estimate provided to the uninsured or self-pay individual for the item or service under dispute the copy can be a photocopy or an electronic image so long as the document is readable;
B A copy of the billed charges provided to the uninsured or self-pay individual for the item or service under dispute the copy can be a photocopy or an electronic image so long as the document is readable; and C If available, documentation demonstrating that the difference between the billed charge and the expected charges in the good faith estimate reflects the cost 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.
ii Timeframe for SDR entity determination. Not later than 30
business days after receipt of the information described in paragraph f2i of this section, the SDR entity must make a determination regarding the amount to be paid by such uninsured or self-pay individual, taking into account the requirements in paragraph f3 of this section.
3 Payment determination by an SDR
entityi In general. The SDR entity must review any documentation submitted by the uninsured or self-pay individual, and the provider or the facility, and make a separate determination for each unique item or service charged as to whether the provider or facility has provided credible information to demonstrate that the difference between the billed charge and the expected charge for the item or service in the good faith estimate 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.
ii Definition of credible information.
Credible information means information that upon critical analysis is worthy of belief and is trustworthy.

PO 00000

Frm 00162

Fmt 4701

Sfmt 4700

iii Payment determination process.
A For an item or service that appears on the good faith estimate:
1 If the billed charge is equal to or less than the expected charge for the item or service in the good faith estimate, the SDR entity must determine the amount to be paid for the item or service as the billed charge.
2 If the billed charge for the item or service is greater than the expected charge in the good faith estimate, and the SDR entity determines that information submitted by the provider or facility does not provide credible information that the difference between the billed charge and the expected charge-for the item or service in the good faith estimate 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 determine the amount to be paid for the item or service to be equal to the expected charge for the item or service in the good faith estimate.
3 If the billed charge for the item or service is greater than the expected charge in the good faith estimate, and the SDR entity determines that information submitted by the provider or facility provides credible information that the difference between the billed charge and the expected charge for the item or service in the good faith estimate 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 determine as the amount to be paid for the 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, except that in cases where the amount determined by an independent database is determined to be less than the expected charge for the item or service listed on the good faith estimate, the amount to be paid will equal to the expected charge for the item or service listed on the good faith estimate. When comparing the billed charge with the amount contained in an independent database, the SDR entity
E:FRFM07OCR2.SGM

07OCR2