02-031 C.M.R. ch. 365, § 4 - Application for Selection as an IDRE

An entity applying for selection as an IDRE shall submit to the Superintendent an application on the form prescribed by the Superintendent. The application must describe the proposed IDRE's organizational structure and capability to operate a statewide IDR process, including:

1. copies of its certificate of incorporation or articles of organization, bylaws or operating agreement, and, as applicable, those of its holding company or parent company;

2. its organizational chart;

3. the names and biographical information relevant to the business of independent dispute resolution services for all members of its board of directors, its officers, and its executives, including their respective roles, and responsibilities;

4. the names of all corporations and organizations that it controls, is controlled by, or is under common control with, and the nature and extent of that control;

5. its policies and procedures governing all aspects of the IDR process, including at a minimum:

A. a description and a chart or diagram of the sequence of steps through which a dispute will move from receipt through notification of the dispute determination to interested parties;

B. procedures for ensuring that the arbitrator assigned to a dispute has no prohibited material financial, material personal, or material professional affiliation. These procedures must include a requirement for a signed attestation by each arbitrator assigned to review a dispute;

C. procedures to ensure that each dispute is reviewed by a neutral and impartial arbitrator with training and experience in healthcare billing, reimbursement, and usual and customary charges;

D. procedures for reporting and reviewing an arbitrator's conflicts of interest, for determining whether there is a conflict of interest, and for assigning or reassigning an IDR where a conflict is identified;

E. procedures to ensure that reviews are conducted within the time frames specified in this rule and any required notices are provided in a timely manner;

F. procedures to ensure the confidentiality of personal health information, personally identifiable information, and review materials;

G. procedures to ensure adherence to the requirements of this rule by any contractor, subcontractor, agent, or employee;

H. a description of the following:

(1) its ability to provide review services statewide;

(2) the qualifications the arbitrators retained to review payment disputes, including current and past employment history, as applicable;

(3) the procedures employed to ensure that arbitrators reviewing payment disputes are:

(a) trained in the principles of dispute resolution and the procedures and standards of the proposed IDRE;

(b) knowledgeable about the health care service which is the subject of the payment dispute under review; and

(c) trained and experienced in health care billing, reimbursement and usual and customary charges;

(4) the methods of recruiting and selecting neutral and impartial arbitrators and matching such reviewers to specific cases;

I. its organizational arrangements and ongoing procedures for the identification, evaluation, resolution, and follow-up of potential and actual problems in payment dispute reviews; and the maintenance of program standards pursuant to this subdivision;

J. written procedures documenting that:

(1) appropriate personnel are reasonably accessible at least 40 hours per week during normal business hours to discuss the dispute resolution process and to allow response to telephone requests; and

(2) a response to an answered call or recorded message shall be made no later than the next business day after the call was received;

K. its fees, which must include disclosure of:

(1) the total amount that it will charge for reviews, inclusive of indirect costs, administrative fees and incidental expenses;

(2) the pro-rated fee that will be charged when a good faith negotiation directed by the proposed IDRE results in a settlement between a carrier and a provider;

(3) an application processing fee if the dispute is determined by the proposed IDRE to be ineligible for review;

(4) the fee that will be charged to the provider when an eligible patient requests an IDR;

(5) the methodology used to calculate all fees; and

(6) any fee charged for the configuration of a portal to receive IDR applications from out-of-network providers and eligible patients;

L. how it provides requisite notifications, screens for material affiliations, responds during normal business hours to inquiries from the State and from interested persons regarding the dispute resolution process; and

M. such other information as the Superintendent may require.

Notes

02-031 C.M.R. ch. 365, § 4