02-031 C.M.R. ch. 365, § 7 - Process to Submit and Resolve Disputes

1. The out-of-network provider or eligible patient requesting IDR (the "applicant") shall submit an application in a form and manner prescribed by the Superintendent.

2. The applicant shall provide the following information, to the extent known to the applicant:

A. the name and contact information of the patient, the provider or providers, and, unless the applicant is an uninsured patient, the carrier or self-insured health benefit plan;

B. the fee that is the subject of the dispute and a copy of the bill;

C. the claim number or numbers and date or dates of service;

D. if the application is submitted by a provider, the following additional information:

(1) the provider's level of training, education, and experience;

(2) an explanation of the circumstances and complexity of the particular case, including time and place of the service;

(3) individual patient characteristics, if relevant; and

(4) the provider's usual charge for comparable services rendered to uninsured patients, patients treated on an out-of-network basis, patients treated under contracts with other carriers or self-insured plans, and, if applicable, patients treated under a contract with the carrier or plan involved in the dispute that was terminated or that expired within one year before the date the service was rendered;

E. an agreement to be bound by the outcome of the IDR, to submit to the jurisdiction of the Superintendent and the courts of this State, and if the applicant is an out-of-network provider, to refrain from billing the enrollee more than the applicable out-of-pocket costs permitted by 22 M.R.S. §1718(D)(2).

F. any other information the applicant deems relevant; and

G. an attestation affirming that the information provided by the applicant is true and accurate.

3. An eligible patient shall not be required to pay the provider's fee in order to be eligible to submit the dispute for review by an IDRE.

4. If the Superintendent chooses to screen applications for eligibility, the Superintendent shall promptly notify all parties upon determining that an application is ineligible for IDR, and shall assign each eligible application to an IDRE and promptly forward the application materials to the assigned IDRE. Otherwise, the Superintendent shall assign each application to an IDRE, which shall screen the application for eligibility within three business days. The IDRE shall contact the applicant, and any other party that might have the necessary information, if additional information is needed to determine eligibility of the request for IDR. The IDRE shall allow a reasonable time, not less than three business days, to submit the information and provide an explanation of where the information should be sent. If the information is not submitted, the IDRE shall make a second request and allow one business day to submit the information.

5. Within three business days after an application has been determined to be eligible, the IDRE shall assign an arbitrator and notify the patient, the provider or providers, and, if applicable, the carrier or self-insured plan. The notification shall include:

A. the name and contact information of the IDRE and the assigned arbitrator;

B. a brief description of the process, and the parties' rights and responsibilities, including:

(1) if the IDR was initiated by the provider, an explanation that the disputed bill is the carrier's responsibility and the patient's cost-sharing obligation cannot be increased as a result of the IDR; and

(2) if the patient is enrolled in a nonparticipating self-insured plan, an explanation that any participation by the plan in the IDR process, including the provision of any requested information, is voluntary; and

C. an explanation of how and where each party may send the arbitrator any additional information it considers important to a clear understanding and fair resolution of the dispute, and the deadline for submitting such information.

6. The arbitrator may request information at any time from the patient, the provider or providers, and the carrier or self-insured plan, and shall advise the requested party that if a partial response or no response is received, the dispute will be decided based on the available information. Any party shall provide the information requested within the time requested, which shall be no less than five business days after the request is received, and shall attest that the information provided is true and complete.

7. In resolving a dispute, the IDRE must consider all relevant factors, including but not limited to the factors identified in 24-A M.R.S. §4303-E(1)(C)(1)-(3).

8. The IDRE shall issue its decision within thirty days after its receipt of a completed application.

9. The party responsible for payment of the IDRE's fee, or its share of the fee in the case of a negotiated settlement, shall pay the IDRE within 90 days after the issuance of the decision or submission of the settlement agreement.

Notes

02-031 C.M.R. ch. 365, § 7