Federal Independent Dispute Resolution Operations; Correction

Issuing agencies

Abstract

This document corrects typographical errors and omissions in the final rule that appeared in the June 4, 2026, Federal Register titled "Federal Independent Dispute Resolution Operations" (referred to hereafter as the "IDR final rule"). The effective date of the IDR final rule was August 3, 2026.

Full Text

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<title>Federal Register, Volume 91 Issue 166 (Friday, August 28, 2026)</title>
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[Federal Register Volume 91, Number 166 (Friday, August 28, 2026)]
[Rules and Regulations]
[Pages 55462-55473]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2026-17622]


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DEPARTMENT OF THE TREASURY

Internal Revenue Service

26 CFR Part 54

[TD 10049]
RIN 1545-BQ55

DEPARTMENT OF LABOR

Employee Benefits Security Administration

29 CFR Part 2590

RIN 1210-AC17

DEPARTMENT OF HEALTH AND HUMAN SERVICES

45 CFR Part 149

[CMS-9897-F2]
RIN 0938-AV15


Federal Independent Dispute Resolution Operations; Correction

AGENCY: Office of Personnel Management; Internal Revenue Service, 
Department of the Treasury; Employee Benefits Security Administration, 
Department of Labor; Centers for Medicare & Medicaid Services, 
Department of Health and Human Services.

ACTION: Correcting amendment.

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SUMMARY: This document corrects typographical errors and omissions in 
the final rule that appeared in the June 4, 2026, Federal Register 
titled ``Federal Independent Dispute Resolution Operations'' (referred 
to hereafter as the ``IDR final rule''). The effective date of the IDR 
final rule was August 3, 2026.

DATES: 

[[Page 55463]]

    Effective date: This correcting amendment is effective on August 
28, 2026.
    Applicability date: The corrections indicated in this document are 
applicable beginning on August 3, 2026.

FOR FURTHER INFORMATION CONTACT: Cameron Stokes, Office of Personnel 
Management, at (202) 936-0162; Alexander Krupnick, Internal Revenue 
Service, Department of the Treasury, at (202) 317-5500; Elizabeth 
Schumacher or Rebecca Miller, Employee Benefits Security 
Administration, Department of Labor, at (202) 693-8335; Camille Henley, 
Centers for Medicare & Medicaid Services, Department of Health and 
Human Services, at (410) 786-1492.

SUPPLEMENTARY INFORMATION:

I. Background

    In FR Doc. 2026-11140 of June 4, 2026 (91 FR 33900), there were 
typographical errors and omissions that are identified and corrected in 
this correcting document.

II. Summary of Errors in Regulations Text

    On page 34047, in amendatory instruction 6.a. for Sec.  54.9816-6, 
we did not specify ``introductory text'' after paragraph (a) and 
therefore, regulation text was inadvertently omitted.
    On page 34054, Sec.  54.9816-8(c)(5), we inadvertently omitted 
regulation text for paragraphs (c)(5)(vii)(A)(1) and (2) after 
paragraph (c)(5)(vii)(A) introductory text.
    On page 34057, Sec.  54.9816-8(h)(1), we inadvertently included the 
word ``revised''.
    On page 34057, Sec.  54.9816-8(h)(3), we incorrectly formatted the 
second cross-reference to paragraph (c)(1) of that section.
    On page 34057, Sec.  54.9816-8(h)(4), we incorrectly formatted the 
cross-references to paragraphs (c)(3)(i) and (c)(3)(ii)(C) and (D) and 
paragraphs (c)(2), (c)(3)(ii)(A) and (B), and (c)(4) of that section.
    On page 34057, Sec.  54.9816-8(h)(5), we incorrectly formatted the 
cross-references to paragraphs (c)(5)(i) and (ii) and (c)(5)(vii)(B) 
and (C) of that section.
    On page 34057, Sec.  54.9816-8(h)(9), we incorrectly formatted the 
second cross-reference to paragraph (g) of that section.
    On page 34057, Sec.  54.9816-8(h)(10), we inadvertently used the 
word ``section'' instead of the word ``requirements'' in a cross-
reference to that section.
    On pages 34059 through 34060, in amendatory instructions 13.a. 
through 13.h. for Sec.  2590.716-8, we included instructions for 
individual revisions to paragraph (b) rather than stating that 
paragraph (b) was being revised in its entirety.
    On page 34060, in amendatory instruction 13.l. for Sec.  2590.716-
8, we included instructions for individual revisions to paragraph 
(c)(4) rather than stating that paragraph (c)(4) was being revised in 
its entirety, and we inadvertently omitted the revision to paragraph 
(c)(5)(iii).
    On page 34063, Sec.  2590.716-8(c)(1)(i), we incorrectly formatted 
the cross-reference to paragraph (b)(2)(iii)(A)(11) of that section.
    On page 34065, Sec.  2590.716-8(c)(4)(i), we incorrectly formatted 
the cross-reference to that paragraph.
    On page 34066, Sec.  2590.716-8(c)(5)(ii)(A), we incorrectly 
formatted the second cross-reference to paragraph (c)(5)(i) of that 
section and inadvertently omitted a closing parenthesis.
    On page 34066, Sec.  2590.716-8(c)(5)(ii)(B), we incorrectly 
formatted the cross-reference to paragraph (c)(5)(vi) of that section.
    On page 34066, Sec.  2590.716-8(c)(5)(iii)(D), we inadvertently 
referenced ``(c)(4)(v)'' rather than ``(c)(5)(v)''.
    On page 34066, we inadvertently omitted the text of Sec.  2590.716-
8(c)(5)(vii)(A)(1) and (2).
    On page 34068, Sec.  2590.716-8(h)(1), we inadvertently included 
the word ``revised''.
    On page 34068, Sec.  2590.716-8(h)(3), we incorrectly formatted the 
second cross-reference to paragraph (c)(1) of that section.
    On page 34068, Sec.  2590.716-8(h)(4), we incorrectly formatted the 
cross-references to paragraphs (c)(3)(i) and (c)(3)(ii)(C) and (D) and 
paragraphs (c)(2), (c)(3)(ii)(A) and (B), and (c)(4) of that section.
    On page 34068, Sec.  2590.716-8(h)(5), we incorrectly formatted the 
cross-references to paragraphs (c)(5)(i) and (ii) and (c)(5)(vii)(B) 
and (C) of that section.
    On page 34068, Sec.  2590.716-8(h)(9), we incorrectly formatted the 
second cross-reference to paragraph (g) of that section.
    On page 34068, Sec.  2590.716-8(h)(10), we inadvertently used the 
word ``section'' instead of the word ``requirements'' in a cross-
reference to that section.
    On page 34069, Sec.  2590.716-9(c)(2), we inadvertently referenced 
``2590.716A-6'' rather than ``2590.716-6A''.
    On page 34076, Sec.  149.510(c)(4)(i) we stated ``of this section'' 
to an already cross-referenced paragraph and inadvertently included an 
asterisks placeholder.
    On page 34076, Sec.  149.510(c)(5)(i) we inadvertently included an 
asterisks placeholder.
    On page 34077, Sec.  149.510(c)(5)(ii)(B), we inadvertently omitted 
the word ``paragraph''.
    On page 34077, Sec.  149.510(c)(5)(iii)(D), we inadvertently 
referenced ``(c)(4)(v)'' rather than ``(c)(5)(v)''.
    On page 34077, Sec.  149.510(c)(5)(vii)(A), we inadvertently 
included an asterisks placeholder.
    On page 34077, Sec.  149.510(c)(5)(vii)(C), we inadvertently 
italicized ``(c)(5)(vii)(C)''.
    On page 34078, Sec.  149.510(c)(5)(vii), we inadvertently included 
an asterisks placeholder.
    On page 34079, Sec.  149.510(h)(1), we inadvertently included the 
word ``revised''.
    On page 34079, Sec.  149.510(h)(3), we incorrectly formatted the 
second cross-reference to paragraph (c)(1) of that section.
    On page 34079, Sec.  149.510(h)(4), we incorrectly formatted the 
cross-references to paragraphs (c)(3)(i) and (c)(3)(ii)(C) and (D) and 
paragraphs (c)(2), (c)(3)(ii)(A) and (B), and (c)(4) of that section.
    On page 34079, Sec.  149.510(h)(5), we incorrectly formatted the 
cross-references to paragraphs (c)(5)(i) and (ii) and (c)(5)(vii)(B) 
and (C) of that section.
    On page 34079, Sec.  149.510(h)(9), we incorrectly formatted the 
second cross-reference to paragraph (g) of that section.
    On page 34079, Sec.  149.510(h)(10), we inadvertently used the word 
``section'' instead of the word ``requirements'' in a cross-reference 
to that section.
    Due to the errors noted in this correcting amendment for Sec.  
149.510(c) and incomplete regulations text in the IDR final rule, we 
are including the regulations text for paragraph (c) in its entirety.

III. Waiver of Proposed Rulemaking and Delay in Effective Date

    Under the Administrative Procedure Act (APA) (5 U.S.C. 551, et 
seq.), a general notice of proposed rulemaking and an opportunity for 
public comment is generally required before the promulgation of 
regulations. The APA also generally requires that a final rule be 
effective no sooner than 30 days after the date of publication in the 
Federal Register.
    Sections 553(b)(B) and 553(d)(3) of the APA provide for exceptions 
from the APA notice and comment and delay in effective date 
requirements. Section 553(b)(B) of the APA authorizes an

[[Page 55464]]

agency to dispense with normal notice and comment rulemaking procedures 
for good cause if the agency makes a finding that the notice and 
comment process is impracticable, unnecessary, or contrary to the 
public interest and includes a statement of the finding and the reasons 
for it in the rule. Similarly, section 553(d)(3) of the APA allows the 
agency to avoid the 30-day delay in effective date where good cause is 
found and the agency includes in the rule a statement of the finding 
and the reasons for it.
    The Departments are publishing this technical correction without 
advance notice or an opportunity for comment because notice and comment 
would be unnecessary under the APA, 5 U.S.C. 553(b)(B). The Departments 
are also waiving the 30-day delay in effective date for these 
corrections because a delayed effective date would be contrary to the 
public interest under the APA, 5 U.S.C. 553(d)(3).
    This document corrects technical and typographical errors made in 
the final rules, which were published in accordance with the APA after 
the Departments proposed the rules and provided the public with an 
opportunity to comment on the proposals. The corrections contained in 
this document do not make any substantive changes to the policies 
adopted in the final rules. Where this document makes technical and 
typographical corrections to the amendatory instructions of the 
regulations text and regulatory text, it makes no changes to any 
substantive requirements. Where this document makes substantive changes 
to the regulatory text to correct typographical errors, the changes 
reflect the policies described in the proposed and final rules which 
were subject to notice and comment as required under the APA. If the 
corrections in this document were proposed and subjected to notice and 
comment, there would be nothing of substance on which the public could 
comment. Therefore, the Departments find that notice and comment would 
be unnecessary and there is good cause to waive the notice and comment 
requirement under the APA, 5 U.S.C. 553(b)(B).
    The Departments are also waiving the 30-day delay in effective date 
for these corrections. It is in the public interest to ensure that the 
final rules setting forth requirements for group health plans, health 
insurance issuers offering group or individual health insurance 
coverage, providers, facilities, and providers of air ambulance 
services relating to participation in the Federal IDR process 
accurately describe the Departments' policies as of the date they take 
effect. Therefore, the Departments find that delaying the effective 
date of these corrections beyond the August 3, 2026, effective date of 
the final rules would be contrary to the public interest. In doing so, 
the Departments find good cause to waive the 30-day delay in the 
effective date.

List of Subjects

26 CFR Part 54

    Excise taxes, Pensions, Reporting and recordkeeping requirements.

29 CFR Part 2590

    Continuation coverage, Disclosure, Employee benefit plans, Group 
health plans, Health care, Health insurance, Medical child support, 
Reporting and recordkeeping requirements.

45 CFR Part 149

    Balance billing, Health care, Health insurance, Reporting and 
recordkeeping requirements, State regulation of health insurance, 
Surprise billing, Transparency in coverage.

DEPARTMENT OF THE TREASURY

Internal Revenue Service

    Accordingly, 26 CFR part 54 is corrected by making the following 
correcting amendments:

PART 54--PENSION EXCISE TAXES

0
Par. 1. The authority citation for part 54 continues to read in part as 
follows:

    Authority: 26 U.S.C. 7805 * * *
* * * * *

0
Par. 2. Section 54.9816-6 is amended by revising paragraph (a) to read 
as follows:


Sec.  54.9816-6  Methodology for calculating qualifying payment amount.

    (a) Definitions. For further guidance, see 29 CFR 2590.716-6(a) 
introductory text through (a)(17).
    (1)-(17) [Reserved]
    (18) Downcode means the alteration by a plan or issuer of a service 
code to another service code, or the alteration, addition, or removal 
by a plan or issuer of a modifier, if the changed code or modifier is 
associated with a lower qualifying payment amount than the service code 
or modifier billed by the provider, facility, or provider of air 
ambulance services.
* * * * *

0
Par. 3. Section 54.9816-8 is amended--
0
a. By revising paragraph (c)(5)(vii)(A);
0
b. In paragraph (h)(1), by removing the word ``revised'' before 
``definition for batched'';
0
c. In paragraph (h)(3), by removing the phrase ``the modifications at 
paragraph (c)(1) of this section are'' and adding in its place 
``paragraph (c)(1) of this section is'';
0
d. In paragraph (h)(4), by removing the phrases ``The modifications at 
paragraphs'' and ``The amendments at paragraphs'' and adding in their 
place ``Paragraphs'';
0
e. In paragraph (h)(5), by removing the phrase ``The modifications at 
paragraphs'' and adding in its place ``Paragraphs'';
0
f. In paragraph (h)(9), by removing the phrase ``The modifications at 
paragraph (g) of this section are'' and adding in its place ``Paragraph 
(g) of this section is''; and
0
g. In paragraph (h)(10), by removing the phrase ``the corresponding 
section of Sec.  54.9816-8'' and adding in its place ``the 
corresponding requirements of Sec.  54.9816-8''.
    The revision reads as follows:


Sec.  54.9816-8  Independent dispute resolution process.

* * * * *
    (c) * * *
    (5) * * *
    (vii) * * *
    (A) Binding. A determination made by a certified IDR entity under 
paragraph (c)(5)(ii) of this section:
    (1) Is binding upon the parties, in the absence of fraud or 
evidence of intentional misrepresentation of material facts presented 
to the certified IDR entity regarding the claim; and
    (2) Is not subject to judicial review, except in a case described 
in any of paragraphs (1) through (4) of section 10(a) of title 9, 
United States Code.
* * * * *

DEPARTMENT OF LABOR

Employee Benefits Security Administration

    For the reasons stated in the preamble, the Department of Labor 
amends 29 CFR part 2590 by making the following correcting amendments:

PART 2590--RULES AND REGULATIONS FOR GROUP HEALTH PLANS

0
4. The authority citation for part 2590 continues to read as follows:

    Authority: 29 U.S.C. 1027, 1059, 1135, 1161-1168, 1169, 1181-
1183, 1181 note, 1185, 1185a-n, 1191, 1191a, 1191b, and 1191c; sec. 
101(g), Pub. L. 104-191, 110 Stat. 1936; sec. 401(b), Pub. L. 105-
200, 112 Stat. 645 (42 U.S.C. 651 note); sec. 512(d), Pub. L. 110-
343, 122 Stat. 3881; sec. 1001, 1201, and 1562(e), Pub. L. 111-148, 
124 Stat. 119, as amended by Pub. L. 111-152, 124 Stat. 1029;

[[Page 55465]]

Division M, Pub. L. 113-235, 128 Stat. 2130; Pub. L. 116-260, 134 
Stat. 1182; Secretary of Labor's Order 1-2011, 77 FR 1088 (Jan. 9, 
2012).

0
5. Section 2590.716-8 is amended--
0
a. By revising paragraph (b);
0
b. In paragraph (c)(1)(i) introductory text, by removing the phrase 
``subordinate paragraph (b)(2)(iii)(A)(11) thereof'' and adding in its 
place ``paragraph (b)(2)(iii)(A)(11) of this section'';
0
c. In paragraph (c)(4)(i) introductory text, by removing the phrase 
``of this section'';
0
d. In paragraph (c)(5)(ii)(A) introductory text, by removing the 
regulatory citation ``29 CFR 2590.716-8(c)(5)(i)'' and adding in its 
place ``paragraph (c)(5)(i) of this section)'';
0
e. In paragraph (c)(5)(ii)(B), by adding the word ``paragraph'' before 
``(c)(5)(vi) of this section'';
0
f. By revising paragraph (c)(5)(iii);
0
g. By adding paragraphs (c)(5)(vii)(A)(1) and (2);
0
h. In paragraph (h)(1), by removing the word ``revised'' before 
``definition for batched'';
0
i. In paragraph (h)(3), by removing the phrase ``the modifications at 
paragraph (c)(1) of this section are'' and adding in its place 
``paragraph (c)(1) of this section is'';
0
j. In paragraph (h)(4), by removing the phrases ``The modifications at 
paragraphs'' and ``The amendments at paragraphs'' and adding in their 
place ``Paragraphs'';
0
k. In paragraph (h)(5), by removing the phrase ``The modifications at 
paragraphs'' and adding in its place ``Paragraphs'';
0
l. In paragraph (h)(9), by removing the phrase ``The modifications at 
paragraph (g) of this section are'' and adding in its place ``Paragraph 
(g) of this section is''; and
0
m. In paragraph (h)(10), by removing the phrase ``the corresponding 
section of Sec.  2590.716-8'' and adding in its place ``the 
corresponding requirements of Sec.  2590.716-8''.
    The revisions and additions read as follows:


Sec.  2590.716-8  Independent dispute resolution process.

* * * * *
    (b) Determination of payment amount through open negotiation and 
initiation of the Federal IDR process--(1) Determination of payment 
amount through open negotiation--(i) In general. For an item or service 
that meets the requirements of paragraph (a)(2)(xi)(A) of this section, 
the provider, facility, or provider of air ambulance services or the 
group health plan or health insurance issuer offering group or 
individual health insurance coverage may, during the 30-business-day 
period beginning on the day the provider, facility, or provider of air 
ambulance services receives an initial payment or notice of denial of 
payment regarding the item or service, initiate a 30-business-day open 
negotiation period for purposes of determining the out-of-network rate 
for such item or service. To initiate the open negotiation period, a 
party must submit a written open negotiation notice with the content 
specified in paragraph (b)(1)(ii) of this section to the other party 
and to the Secretary in the manner specified in paragraph (b)(3) of 
this section. The 30-business-day open negotiation period begins on the 
day on which the party first submits the open negotiation notice, 
including the remittance advice documentation specified in paragraph 
(b)(1)(ii)(A)(12) of this section to the other party and the Secretary. 
The party in receipt of the open negotiation notice must provide to the 
party that initiated open negotiation and to the Secretary in the 
manner specified in paragraph (b)(3) of this section, as soon as 
practicable, but no later than the 15th business day of the 30-
business-day open negotiation period, a written notice and supporting 
documentation in response to the open negotiation notice, as specified 
in paragraph (b)(1)(iii)(A) of this section.
    (ii) Open negotiation notice--(A) Content. The open negotiation 
notice must include, for the item or service that is the subject of the 
open negotiation notice, information about the item or service and the 
parties, including:
    (1) Information sufficient to identify the provider, facility, or 
provider of air ambulance services, including the name and current 
contact information (including the legal business name, email address, 
phone number, and mailing address) as provided with the claim form 
submitted by the provider, facility, or provider of air ambulance 
services to the plan or issuer, and the applicable National Provider 
Identifier (NPI);
    (2) Information sufficient to identify the plan or issuer, 
including the plan's or issuer's registration number, as required under 
Sec.  2590.716-9, or an attestation from the party submitting the open 
negotiation notice that the plan's or issuer's registration number was 
not provided on any remittance advice associated with the initial 
payment or notice of denial of payment for the item or service; the 
legal business name of the plan or issuer (or, in the case of a self-
insured group health plan that does not have a legal business name, the 
legal business name of the plan sponsor), as well as the current 
contact information (name, email address, phone number, and mailing 
address) of the plan or issuer as provided with any remittance advice 
associated with the initial payment or notice of denial of payment for 
the item or service; and if the party submitting the open negotiation 
notice is a plan or issuer, the plan type (for example, self-insured or 
fully-insured);
    (3) The name and contact information (including the legal business 
name, email address, phone number, and mailing address) for any third 
party representing the party submitting the open negotiation notice, 
and an attestation that the third party has the authority to act on 
behalf of the party it represents in the open negotiation;
    (4) Information sufficient to identify the item or service, 
including: the date(s) the item or service was furnished and, if the 
party submitting the open negotiation notice is a provider, facility, 
or provider of air ambulance services, the date(s) that the provider, 
facility, or provider of air ambulance services received the initial 
payment or notice of denial of payment for the item or service from the 
plan or issuer; the type of item or service (specifically, whether the 
item or service is an emergency service as defined in Sec.  2590.716-
4(c)(2)(i) or (ii), a non-emergency service as described in Sec.  
2590.716-5(b), or an air ambulance service as defined in Sec.  
2590.716-3); whether the service is a professional service or facility-
based service; the State where the item or service was furnished; the 
claim number; the service code; and information to identify the 
location where the item or service was furnished (such as, place of 
service code or bill type code);
    (5) The initial payment amount (including $0 if payment is denied);
    (6) The qualifying payment amount, if provided in a remittance 
advice associated with the initial payment or notice of denial of 
payment, or if the party submitting the open negotiation notice is a 
plan or issuer;
    (7) An offer of an out-of-network rate for each item or service;
    (8) If the party submitting the open negotiation notice is a plan 
or issuer, the amount of cost sharing imposed for the item or service, 
if any;
    (9) If the party submitting the open negotiation notice is a 
provider or facility, a statement that the items and services do not 
qualify for the notice and consent exception described at 45 CFR 
149.410(b) or 149.420(c) through (i);
    (10) A statement that the provider, facility, or provider of air 
ambulance

[[Page 55466]]

services was a nonparticipating provider, nonparticipating emergency 
facility, or nonparticipating provider of air ambulance services on the 
date the item or service was furnished;
    (11) General information listed in the standard open negotiation 
notice developed by the Secretary pursuant to paragraph (b)(3) of this 
section describing the open negotiation period and the Federal IDR 
process (including a description of the purpose of the open negotiation 
period and Federal IDR process and key deadlines in the open 
negotiation period and Federal IDR process); and
    (12) A copy of any remittance advice associated with the initial 
payment or notice of denial of payment for the item or service.
    (B) [Reserved]
    (iii) Open negotiation response notice--(A) Content. The response 
to the open negotiation notice must include, for the item or service 
that is the subject of the open negotiation response notice, 
information about the item or service and the parties, including:
    (1) Information sufficient to identify the provider, facility, or 
provider of air ambulance services, including the name and current 
contact information (including the legal business name, email address, 
phone number, and mailing address) as provided with the claim form 
submitted by the provider, facility, or provider of air ambulance 
services to the plan or issuer, and the applicable NPI;
    (2) Information sufficient to identify the plan or issuer, 
including the plan's or issuer's registration number, as required under 
Sec.  2590.716-9, or an attestation from the party submitting the open 
negotiation response notice that the plan's or issuer's registration 
number was not provided on any remittance advice associated with the 
initial payment or notice of denial of payment for the item or service, 
as well as the legal business name of the plan or issuer (or, in the 
case of a self-insured group health plan that does not have a legal 
business name, the legal business name of the plan sponsor), the 
current contact information (name, email address, phone number, and 
mailing address) of the plan or issuer as provided with any remittance 
advice associated with the initial payment or notice of denial of 
payment for the item or service; and if the party submitting the open 
negotiation response notice is a plan or issuer, the plan type (for 
example, self-insured or fully-insured);
    (3) The name and contact information (including the legal business 
name, email address, phone number, and mailing address) for any third 
party representing the party submitting the open negotiation response 
notice, and an attestation that the third party has the authority to 
act on behalf of the party it represents in the open negotiation;
    (4) Information sufficient to identify the item or service included 
in the open negotiation notice, including the date(s) the item or 
service was furnished, and if the party submitting the open negotiation 
response notice is a provider, facility, or provider of air ambulance 
services, the date(s) that the provider, facility, or provider of air 
ambulance services received the initial payment or notice of denial of 
payment for the item or service from the plan or issuer, and the claim 
number;
    (5) If the party submitting the open negotiation response notice is 
a plan or issuer, a statement as to whether it agrees that the initial 
payment amount (including $0 if payment is denied) and the qualifying 
payment amount reflected in the open negotiation notice accurately 
reflect the initial payment amount and qualifying payment amount 
disclosed with the initial payment for the item or service, and if not, 
or if the open negotiation notice indicates that the initial payment 
amount or qualifying payment amount was not communicated by the plan or 
issuer in a remittance advice associated with the initial payment or 
notice of denial of payment, the initial payment amount (including $0 
if payment is denied) and/or qualifying payment amount it believes to 
be correct, and documentation to support the statement (for example, 
the remittance advice confirming the qualifying payment amount);
    (6) If the party submitting the open negotiation response notice is 
a plan or issuer, the amount of cost sharing imposed for the item or 
service, if any;
    (7) If the party submitting the open negotiation response notice is 
a provider or facility, a statement that the items and services do not 
qualify for the notice and consent exception described at 45 CFR 
149.410(b) or 149.420(c) through (i);
    (8) For each item or service, either a statement and supporting 
documentation that explains why the item or service is not subject to 
the Federal IDR process or a statement agreeing that the item or 
service is subject to the Federal IDR process;
    (9) A statement as to whether any of the information provided in 
the open negotiation notice is inaccurate and the basis for the 
statement, as well as supporting documentation; and
    (10) A statement confirming that the initial payment or notice of 
denial of payment or other remittance advice reflected in the open 
negotiation notice under paragraph (b)(1)(ii)(A)(12) of this section is 
accurate, or, if inaccurate, a copy of the accurate remittance advice 
associated with the initial payment or notice of denial of payment for 
the item or service.
    (B) [Reserved]
    (2) Initiating the Federal IDR process--(i) In general. Either 
party may initiate the Federal IDR process for a qualified IDR item or 
service as defined in paragraph (a)(2)(xi) of this section for which 
the parties have not agreed on an out-of-network rate by the last day 
of the open negotiation period provided for under paragraph (b)(1) of 
this section. To initiate the Federal IDR process, a party (the 
initiating party) must submit a written notice of IDR initiation, 
consistent with paragraph (b)(2)(ii) of this section, to the other 
party to the dispute (the non-initiating party) and to the Secretary in 
the manner specified in paragraph (b)(3) of this section, during the 4-
business-day period beginning on the first business day after the last 
day of the open negotiation period (unless it is otherwise required to 
be submitted in the timeframe specified in paragraph (c)(5)(vii)(C) of 
this section). The date of IDR initiation is the date the Secretary 
receives the notice of IDR initiation described in paragraph (b)(2)(ii) 
of this section.
    (A) Exception for items and services provided by certain 
nonparticipating providers and facilities. A party may not initiate the 
Federal IDR process for an item or service if, for that item or 
service, the party knows (or reasonably should have known) that the 
provider or facility provided notice and received consent under 45 CFR 
149.410(b) or 149.420(c) through (i).
    (B) [Reserved]
    (ii) Notice of IDR initiation--(A) Content. The notice of IDR 
initiation must include, for the item or service that is the subject of 
the notice, information about the item or service and the parties, 
including:
    (1) Information sufficient to identify the provider, facility, or 
provider of air ambulance services, including the name and current 
contact information (including the legal business name, email address, 
phone number, and mailing address), and the NPI; and if the initiating 
party is a provider, facility, or provider of air ambulance services, 
the Taxpayer Identification Number (TIN);
    (2) Information sufficient to identify the plan or issuer, 
including the plan's or issuer's registration number, as required under 
Sec.  2590.716-9, or an

[[Page 55467]]

attestation from the initiating party that the plan's or issuer's 
registration number was not provided on any remittance advice 
associated with the initial payment or notice of denial of payment for 
the item or service; the legal business name of the plan or issuer (or, 
in the case of a self-insured group health plan that does not have a 
legal business name, the legal business name of the plan sponsor), as 
well as the current contact information (name, email address, phone 
number, and mailing address) of the plan or issuer as provided with any 
remittance advice associated with the initial payment or notice of 
denial of payment for the item or service; and if the initiating party 
is a plan or issuer, the plan type (for example, self-insured or fully-
insured) and TIN (or, in the case of a plan that does not have a TIN, 
the TIN of the plan sponsor);
    (3) The name and contact information (including the legal business 
name, email address, phone number, TIN, and mailing address) for any 
third party representing the initiating party, and an attestation that 
the third party has the authority to act on behalf of the party it 
represents in the Federal IDR process;
    (4) Information sufficient to identify whether the dispute being 
initiated includes batched or bundled qualified IDR items or services 
as described in paragraph (c)(4) of this section;
    (5) Information sufficient to identify the qualified IDR item or 
service that is the subject of the notice of IDR initiation, including 
the date(s) the qualified IDR item or service was furnished; if the 
initiating party is a provider, facility, or provider of air ambulance 
services, the date(s) that the provider, facility, or provider of air 
ambulance services received the initial payment or notice of denial of 
payment for such item or service from the plan or issuer; the date the 
open negotiation period under paragraph (b)(1) of this section began; 
the type of item or service (specifically, whether the item or service 
that meets the requirements of paragraph (a)(2)(xi)(A) of this section 
is an emergency service as defined in Sec.  2590.716-4(c)(2)(i) or 
(ii), a non-emergency service as described in Sec.  2590.716-5(b), or 
an air ambulance service as defined in Sec.  2590.716-3); whether the 
service is a professional service or facility-based service; the State 
where the item or service was furnished; the claim number; the service 
code; and information to identify the location the item or service was 
furnished (including place of service code or bill type code);
    (6) The initial payment amount (including $0 if payment is denied);
    (7) If the initiating party is a plan or issuer, the amount of cost 
sharing imposed for the item or service, if any;
    (8) The qualifying payment amount, if provided with the initial 
payment or notice of denial of payment, or if the initiating party is a 
plan or issuer;
    (9) If the initiating party is a provider or facility, a statement 
that the items and services do not qualify for the notice and consent 
exception described at 45 CFR 149.410(b) or 149.420(c) through (i);
    (10) A statement that the provider, facility, or provider of air 
ambulance services was a nonparticipating provider, a nonparticipating 
emergency facility, or a nonparticipating provider of air ambulance 
services on the date the item or service was furnished;
    (11) Attestation that the item or service under dispute is a 
qualified IDR item or service as defined in paragraph (a)(2)(xi) of 
this section and is eligible for the Federal IDR process, and the basis 
for the attestation;
    (12) General information listed in the standard notice of IDR 
initiation developed by the Secretary under paragraph (b)(3) of this 
section describing the Federal IDR process (including a description of 
the purpose of the Federal IDR process and key deadlines in the Federal 
IDR process);
    (13) A copy of any remittance advice associated with the initial 
payment or notice of denial of payment for the item or service; and
    (14) Preferred certified IDR entity.
    (B) [Reserved]
    (iii) Notice of IDR initiation response. The non-initiating party 
must provide to the initiating party and the Secretary in the manner 
specified in paragraph (b)(3) of this section within 3 business days 
after the date of IDR initiation, a written notice and supporting 
documentation in response to the notice of IDR initiation, as specified 
in paragraph (b)(2)(iii)(A) of this section.
    (A) Content. The notice of IDR initiation response must include, 
for the item or service that is the subject of the notice, information 
about the item or service and the parties, including:
    (1) Information sufficient to identify the provider, facility, or 
provider of air ambulance services, including the name and current 
contact information (including the legal business name, email address, 
phone number, and mailing address), and the NPI; and if the non-
initiating party is a provider, facility, or provider of air ambulance 
services, the TIN;
    (2) Information sufficient to identify the plan or issuer, 
including the plan's or issuer's registration number, as required under 
Sec.  2590.716-9, or an attestation from the non-initiating party that 
the plan's or issuer's registration number was not provided on any 
remittance advice associated with the initial payment or notice of 
denial of payment for the item or service; the legal business name of 
the plan or issuer (or, in the case of a self-insured group health plan 
that does not have a legal business name, the legal business name of 
the plan sponsor), as well as the current contact information (name, 
email address, phone number, and mailing address) of the plan or issuer 
as provided with any remittance advice associated with the initial 
payment or notice of denial of payment; and if the non-initiating party 
is a plan or issuer, the plan type (for example, self-insured or fully-
insured) and TIN (or, in the case of a plan that does not have a TIN, 
the TIN of the plan sponsor);
    (3) The name and contact information (including the legal business 
name, email address, phone number, TIN, and mailing address) for any 
third party representing the non-initiating party, and an attestation 
that the third party has the authority to act on behalf of the party it 
represents in the Federal IDR process;
    (4) Information sufficient to identify each item or service 
included in the notice of IDR initiation, including the date(s) the 
item or service was furnished and if the non-initiating party is a 
provider, facility, or provider of air ambulance services, the date(s) 
that the provider, facility, or provider of air ambulance services 
received the initial payment or notice of denial of payment for such 
item or service from the plan or issuer, and the claim number;
    (5) If the non-initiating party is a plan or issuer, a statement as 
to whether the non-initiating party agrees that the initial payment 
(including $0 if payment is denied) and the qualifying payment amount 
reflected in the notice of IDR initiation is accurate for the item or 
service that is the subject of the dispute, and if not, the initial 
payment amount (including $0 if payment is denied) and/or qualifying 
payment amount it believes to be correct, and documentation to support 
the statement (for example, the remittance advice confirming the 
qualifying payment amount);
    (6) If the non-initiating party is a plan or issuer, the amount of 
cost sharing imposed for the item or service, if any;
    (7) If the non-initiating party is a provider or facility, a 
statement that the items and services do not qualify for the notice and 
consent exception described at 45 CFR 149.410(b) or 149.420(c) through 
(i);

[[Page 55468]]

    (8) For each item or service that is the subject of the dispute, 
either an attestation that the item or service is a qualified IDR item 
or service as defined in paragraph (a)(2)(xi) of this section and is 
eligible for the Federal IDR process, or for each item or service that 
the non-initiating party asserts is not a qualified IDR item or service 
that is eligible for the Federal IDR process, an explanation and 
documentation to support the assertion;
    (9) A statement confirming that the remittance advice associated 
with the initial payment or notice of denial of payment provided by the 
initiating party under paragraph (b)(2)(ii)(A)(13) of this section is 
accurate, or if inaccurate, a copy of the accurate remittance advice 
associated with the initial payment or notice of denial of payment for 
the item or service;
    (10) A statement as to whether any of the information provided in 
the notice of IDR initiation is inaccurate and the basis for the 
statement, as well as any supporting documentation; and
    (11) A statement as to whether the non-initiating party agrees or 
objects to the initiating party's preferred certified IDR entity. If 
the non-initiating party objects to the initiating party's preferred 
certified IDR entity, the notice of IDR initiation response must 
include the name of an alternative preferred certified IDR entity and, 
if applicable, an explanation of any conflict of interest with the 
initiating party's preferred certified IDR entity.
    (B) [Reserved]
    (3) Manner. A party furnishing notices as required under paragraphs 
(b)(1)(ii) and (iii) and (b)(2)(ii) and (iii) of this section must 
furnish the notices using the standard forms developed by the Secretary 
and must furnish the notices and supporting documentation to the other 
party and the Secretary through the Federal IDR portal.
    (c) * * *
    (5) * * *
    (iii) Considerations in determination. In determining which offer 
to select:
    (A) The certified IDR entity must consider the qualifying payment 
amount(s) for the applicable year for the same or similar item or 
service.
    (B) The certified IDR entity must consider information submitted by 
a party that relates to the following circumstances:
    (1) The level of training, experience, and quality and outcomes 
measurements of the provider or facility that furnished the qualified 
IDR item or service (such as those endorsed by the consensus-based 
entity authorized in section 1890 of the Social Security Act).
    (2) The market share held by the provider or facility or that of 
the plan or issuer in the geographic region in which the qualified IDR 
item or service was provided.
    (3) The acuity of the participant, beneficiary, or enrollee 
receiving the qualified IDR item or service, or the complexity of 
furnishing the qualified IDR item or service to the participant, 
beneficiary, or enrollee.
    (4) The teaching status, case mix, and scope of services of the 
facility that furnished the qualified IDR item or service, if 
applicable.
    (5) Demonstration of good faith efforts (or lack thereof) made by 
the provider or facility or the plan or issuer to enter into network 
agreements with each other, and, if applicable, contracted rates 
between the provider or facility, as applicable, and the plan or 
issuer, as applicable, during the previous 4 plan years.
    (C) The certified IDR entity must also consider information 
provided by a party in response to a request by the certified IDR 
entity under paragraph (c)(5)(i)(A)(2) of this section that relates to 
the offer for the payment amount for the qualified IDR item or service 
that is the subject of the payment determination and that does not 
include information on factors described in paragraph (c)(5)(v) of this 
section.
    (D) The certified IDR entity must also consider additional 
information submitted by a party that relates to the offer for the 
payment amount for the qualified IDR item or service that is the 
subject of the payment determination and that does not include 
information on factors described in paragraph (c)(5)(v) of this 
section.
* * * * *
    (vii) * * *
    (A) * * *
    (1) Is binding upon the parties, in the absence of fraud or 
evidence of intentional misrepresentation of material facts presented 
to the certified IDR entity regarding the claim; and
    (2) Is not subject to judicial review, except in a case described 
in any of paragraphs (1) through (4) of section 10(a) of title 9, 
United States Code.
* * * * *


Sec.  2490.716-9  [Amended]

0
6. Section 2590.716-9 is amended in paragraph (c)(2) by removing the 
reference ``2590.716A-6'' and adding in its place ``2590.716-6A''.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

    For the reasons stated in the preamble, the Department of Health 
and Human Services amends 45 CFR part 149 by making the following 
correcting amendments:

PART 149--SURPRISE BILLING AND TRANSPARENCY REQUIREMENTS

0
7. The authority citation for part 149 continues to read as follows:

    Authority: 42 U.S.C. 300gg-92 and 300gg-111 through 300gg-139, 
as amended.

0
8. Section 149.510 is amended--
0
a. By revising paragraph (c);
0
b. In paragraph (h)(1), by removing the word ``revised'' before 
``definition for batched'';
0
c. In paragraph (h)(3), by removing the phrase ``the modifications at 
paragraph (c)(1) of this section are'' and adding in its place 
``paragraph (c)(1) of this section is'';
0
d. In paragraph (h)(4), by removing the phrases ``The modifications at 
paragraphs'' and ``The amendments at paragraphs'' and adding in their 
place ``Paragraphs'';
0
e. In paragraph (h)(5), by removing the phrase ``The modifications at 
paragraphs'' and adding in its place ``Paragraphs'';
0
f. In paragraph (h)(9), by removing the phrase ``The modifications at 
paragraph (g) of this section are'' and adding in its place ``Paragraph 
(g) of this section is''; and
0
g. In paragraph (h)(10), by removing the phrase ``the corresponding 
section of Sec.  149.510'' and adding in its place ``the corresponding 
requirements of Sec.  149.510''.
    The revision reads as follows:


Sec.  149.510  Independent dispute resolution process.

* * * * *
    (c) Federal IDR process following initiation--(1) Selection of 
certified IDR entity--(i) Preliminary selection of the certified IDR 
entity. Within 3 business days after the date of IDR initiation, the 
non-initiating party must agree or object to the preferred certified 
IDR entity identified in the notice of IDR initiation by submitting the 
notice of IDR initiation response described in paragraph (b)(2)(iii) of 
this section, which contains the information described in paragraph 
(b)(2)(iii)(A)(11) of this section.
    (A) If the non-initiating party agrees or fails to respond to the 
selection of the initiating party's preferred certified IDR entity in 
the manner and timeframe described in this paragraph (c)(1)(i), the 
initiating party's preferred certified IDR entity will be considered 
jointly selected on the third business day after the date of IDR 
initiation.
    (B) If the non-initiating party objects to the selection of the 
initiating party's

[[Page 55469]]

preferred certified IDR entity by designating an alternative preferred 
certified IDR entity in the manner and timeframe described in this 
paragraph (c)(1)(i), the initiating party may then agree or object to 
the non-initiating party's alternative preferred certified IDR entity 
by submitting the notice of certified IDR entity selection in the 
manner specified in paragraph (c)(1)(i)(D) of this section.
    (1) If the initiating party agrees to the non-initiating party's 
alternative preferred certified IDR entity within 3 business days after 
the date of IDR initiation, the alternative preferred certified IDR 
entity will be considered jointly selected by the parties.
    (2) If the non-initiating party submits the notice of IDR 
initiation response on the first or second business day after the date 
of IDR initiation, and the initiating party fails to respond within 3 
business days after the date of IDR initiation, the alternative 
preferred certified IDR entity will be considered jointly selected by 
the parties.
    (3) If the non-initiating party submits the notice of IDR 
initiation response on the third business day after the date of IDR 
initiation and the initiating party fails to respond on the same day, 
selection will proceed pursuant to paragraph (c)(1)(i)(C) of this 
section.
    (C) If a certified IDR entity is not jointly selected under 
paragraph (c)(1)(i)(A) or (B) of this section, either party may select 
an alternative preferred certified IDR entity by submitting the notice 
of certified IDR entity selection in the manner specified in paragraph 
(c)(1)(i)(D) of this section, until the earlier of the date that the 
parties agree on the alternative preferred certified IDR entity or the 
deadline for joint selection, which is 3 business days after the date 
of IDR initiation. Once a party submits a notice of certified IDR 
entity selection, it may not submit another notice of certified IDR 
entity selection until it receives a responding notice of certified IDR 
entity selection from the other party.
    (1) If a party submits a notice of certified IDR entity selection 
to the other party on the first or second business day after the date 
of IDR initiation and the party in receipt of the notice agrees or 
fails to respond to the alternative preferred certified IDR entity by 
the third business day after the date of IDR initiation, the 
alternative preferred certified IDR entity will be considered jointly 
selected by the parties.
    (2) If a party submits a notice of certified IDR entity selection 
to the other party on the third business day after the date of IDR 
initiation and the party last in receipt of the notice agrees to the 
alternative preferred certified IDR entity on the same day, the 
alternative preferred certified IDR entity will be considered jointly 
selected by the parties.
    (3) If a party submits a notice of certified IDR entity selection 
to the other party on the third business day after the date of IDR 
initiation, and the party last in receipt of the notice fails to 
respond to the alternative preferred certified IDR entity on the same 
day, the parties will have failed to jointly select a certified IDR 
entity.
    (D) To notify the other party and the Secretary of an agreement or 
objection to an alternative preferred certified IDR entity as described 
in paragraph (c)(1)(i)(C) of this section, a party must furnish a 
notice of certified IDR entity selection, using the standard form 
developed by the Secretary, to the other party and the Secretary 
through the Federal IDR portal within 3 business days after the date of 
IDR initiation. The notice of certified IDR entity selection must 
include a statement indicating the party's agreement with or objection 
to the other party's alternative preferred certified IDR entity and, if 
applicable, an explanation of any conflict of interest with the 
alternative preferred certified IDR entity, and the name of another 
alternative preferred certified IDR entity. However, in the event the 
conditions for failure to jointly select a certified IDR entity apply, 
selection will proceed in accordance with paragraph (c)(1)(ii) of this 
section.
    (ii) Failure to jointly select a certified IDR entity. If the 
parties fail to jointly select a certified IDR entity within 3 business 
days after the date of IDR initiation, the Secretary will select a 
certified IDR entity. The parties will have failed to jointly select a 
certified IDR entity if, by the end of the third business day after the 
date of IDR initiation, the party last in receipt of the notice of IDR 
initiation response or the notice of certified IDR entity selection has 
received an objection to their preferred or alternative preferred 
certified IDR entity in the applicable notice. Alternatively, the 
parties will have failed to jointly select a certified IDR entity if 
the notice of IDR initiation response or the notice of certified IDR 
entity selection is submitted to the other party on the third business 
day after the date of IDR initiation and the party in receipt of the 
notice fails to respond to the alternative preferred certified IDR 
entity on the same day.
    (A) In selecting the certified IDR entity, the Secretary will first 
confirm whether a party submitted the notice of IDR initiation response 
or the notice of certified IDR entity selection with an alternative 
preferred certified IDR entity on the third business day after the date 
of IDR initiation without the other party's agreement to the selection. 
If either notice was provided on the third business day after the date 
of IDR initiation without the other party's agreement to the 
alternative preferred certified IDR entity by the end of the third 
business day after the date of IDR initiation, the Secretary will 
provide the party last in receipt of the applicable notice, as of the 
end of the third business day after the date of IDR initiation, 2 
additional business days to agree or object to the other party's 
alternative preferred certified IDR entity selection.
    (1) If the party last in receipt of the applicable notice, as of 
the end of the third business day after the date of IDR initiation, 
agrees with the other party's alternative preferred certified IDR 
entity and notifies the Secretary of the agreement, or fails to 
respond, in the Federal IDR portal by the fifth business day after the 
date of IDR initiation, the Secretary will select the final alternative 
preferred certified IDR entity selected in the applicable notice.
    (2) If the party last in receipt of the applicable notice, as of 
the end of the third business day after the date of IDR initiation, 
notifies the Secretary of its objection to the alternative preferred 
certified IDR entity by the fifth business day after the date of IDR 
initiation, the Secretary will randomly select a certified IDR entity 
from among the certified IDR entities (other than the preferred 
certified IDR entity and any alternative preferred certified IDR entity 
previously selected in such dispute by a party, unless there is no 
other certified IDR entity available to select) that charge a fee 
within the allowed range of certified IDR entity fees, not later than 
the sixth business day after the date of IDR initiation. If there are 
insufficient certified IDR entities that charge a fee within the 
allowed range of certified IDR entity fees available to arbitrate the 
dispute, the Secretary will select a certified IDR entity that has 
received approval, as described in paragraph (e)(2)(vii)(A) of this 
section, to charge a fee outside of the allowed range of certified IDR 
entity fees. In either case, the Secretary will notify the parties of 
the preliminary selection of the certified IDR entity not later than 6 
business days after the date of IDR initiation.
    (B) [Reserved]
    (iii) Date of preliminary selection of the certified IDR entity. 
The date of preliminary selection of the certified IDR entity will be:

[[Page 55470]]

    (A) Three business days after the date of IDR initiation if the 
parties jointly select a certified IDR entity, as specified in 
paragraph (c)(1)(i) of this section; or
    (B) Six business days after the date of IDR initiation, if the 
parties fail to jointly select a certified IDR entity as specified in 
paragraph (c)(1)(ii) of this section.
    (iv) Final selection of the certified IDR entity--(A) Conflict-of-
interest review. The certified IDR entity preliminarily selected for a 
dispute must review the selection. The selection of the certified IDR 
entity will be finalized only if the certified IDR entity attests to 
the Secretary that it meets the following requirements:
    (1) The certified IDR entity does not have a conflict of interest 
as defined in paragraph (a)(2)(iv) of this section;
    (2) The certified IDR entity will only assign personnel to a 
dispute and make decisions regarding hiring, compensation, termination, 
promotion, or other similar matters related to personnel assigned to 
the dispute in a manner that is not based upon the likelihood that the 
assigned personnel will support a particular party to the dispute; and
    (3) The certified IDR entity will not assign any personnel to a 
dispute who would have any conflicts of interest, as defined in 
paragraph (a)(2)(iv) of this section, regarding any party to the 
dispute or whose relationship with a party within the 1 year 
immediately preceding the assignment to the dispute would violate the 
restrictions on aiding or advising a former employer or principal in a 
manner similar to the restrictions set forth in 18 U.S.C. 207(b).
    (B) Failure to meet conflict-of-interest requirements. If the 
certified IDR entity fails to attest to the Secretary within 3 business 
days of the date of preliminary selection of the certified IDR entity 
that it meets the requirements of paragraphs (c)(1)(iv)(A)(1) through 
(3) of this section, the Secretary will randomly select another 
certified IDR entity consistent with paragraph (c)(1)(ii) of this 
section. The Secretary will notify the parties of the new randomly 
preliminarily selected certified IDR entity no later than 1 business 
day after the date of preliminary selection of the certified IDR 
entity, no later than 1 business day after the end of the 3-business-
day period.
    (C) Date of final selection of the certified IDR entity. If the 
certified IDR entity that has been preliminarily selected attests 
within 3 business days that it meets the requirements of paragraph 
(c)(1)(iv)(A) of this section, the Secretary will notify the parties of 
the final selection of the certified IDR entity no later than 1 
business day after the certified IDR entity attests that it meets the 
conflict-of-interest requirements. The date of final selection of the 
certified IDR entity is the date that the Secretary provides this 
notice to the parties.
    (2) Federal IDR process eligibility review--(i) Federal IDR process 
eligibility determination by certified IDR entity. The selected 
certified IDR entity must review the information in the notice of IDR 
initiation, notice of IDR initiation response, and any additional 
information described in paragraph (c)(2)(ii) of this section, and make 
a final determination as to whether the item or service is a qualified 
IDR item or service (and in the case of a batched dispute, whether the 
items or services are qualified IDR items or services), as defined in 
paragraph (a)(2)(xi) of this section, that is eligible for the Federal 
IDR process. The certified IDR entity must make such a determination 
and notify the Secretary and both parties no later than 5 business days 
after the date of final selection of the certified IDR entity. If the 
certified IDR entity determines that the item or service is not a 
qualified IDR item or service that is eligible for the Federal IDR 
process, the dispute will be closed, and the selected certified IDR 
entity will not take any further action with respect to the dispute. In 
the case of a batched dispute, only those items and services determined 
to be qualified IDR items or services that are eligible for the Federal 
IDR process and that meet the requirements of paragraph (c)(4)(i) of 
this section will continue through the Federal IDR process, and the 
selected certified IDR entity will not take any further action with 
respect to the other items and services included in the batched 
dispute.
    (ii) Request for additional information. The selected certified IDR 
entity may request additional information from either party to a 
dispute at any time, including for the purpose of assessing whether a 
conflict of interest exists, conducting an eligibility determination, 
or making a payment determination.
    (A) Upon request, a party must submit the additional information 
within 5 business days to the selected certified IDR entity through the 
Federal IDR portal. Following a request for additional information, the 
time period for the applicable stage of the Federal IDR process will be 
tolled until the earlier of the date either all of the requested 
information is provided or the 5-business-day period expires, and each 
subsequent timeframe in the Federal IDR process will be determined 
based on the date of completion of the stage of the Federal IDR process 
that was tolled for provision of the requested information.
    (B) If a party fails to submit the additional information as 
required, the related determination, including the conflict-of-interest 
review, eligibility determination, or payment determination, will be 
made without the requested information unless a good-cause extension of 
the 5-business-day period, as specified in paragraph (g)(1)(i) of this 
section, has been provided, and the party subsequently submits the 
additional information requested within the extended period. If the 
related determination cannot be made because both parties failed to 
provide the additional information as required, the dispute will be 
considered withdrawn, as specified in paragraph (c)(3)(ii) of this 
section.
    (3) Authority to continue negotiations or withdraw--(i) Authority 
to continue to negotiate. If the parties to the Federal IDR process 
agree on an out-of-network rate for a qualified IDR item or service 
after providing the notice of IDR initiation to the Secretary required 
under paragraph (b)(2)(ii) of this section, but before the certified 
IDR entity has made its payment determination, the amount agreed to by 
the parties for the qualified IDR item or service will be treated as 
the out-of-network rate for the qualified IDR item or service. To the 
extent the amount exceeds the initial payment amount and any cost 
sharing paid or owed by the participant, beneficiary, or enrollee, 
payment must be made directly by the plan or issuer to the 
nonparticipating provider, nonparticipating facility, or 
nonparticipating provider of air ambulance services not later than 30 
calendar days after the date the agreement is reached. In no instance 
may either party seek additional payment from the participant, 
beneficiary, or enrollee, calculated based on the agreed-upon amount, 
in instances in which the out-of-network rate exceeds the qualifying 
payment amount. The initiating party must send a notification for the 
parties' agreement to the Secretary and the certified IDR entity (if 
selected) through the Federal IDR portal as soon as possible, but no 
later than 3 business days after the date of the agreement. The 
notification must include the dispute number, a statement of the 
agreed-on out-of-network rate for the qualified IDR item or service, 
and signatures from authorized signatories for both parties.
    (ii) Withdrawal of disputes. A dispute may be withdrawn from the 
Federal IDR process by the initiating party, the

[[Page 55471]]

Secretary, or a certified IDR entity before a payment determination is 
made, if one of the following conditions is met:
    (A) The initiating party provides notification through the Federal 
IDR portal to the Secretary and the certified IDR entity (if selected) 
that both parties to the dispute agree to withdraw the dispute from the 
Federal IDR process without agreement on an out-of-network rate. The 
notification must include the dispute number, a statement about both 
parties' agreement to withdraw, and signatures from authorized 
signatories for both parties;
    (B) The initiating party provides a standard withdrawal request 
notice through the Federal IDR portal to the Secretary, the certified 
IDR entity (if selected), and the non-initiating party of its request 
to withdraw the dispute from the Federal IDR process, and the non-
initiating party notifies the Secretary, certified IDR entity (if 
selected), and the initiating party through the Federal IDR portal of 
its agreement to withdraw from the Federal IDR process within 5 
business days of the initiating party's request. Provision of the 
withdrawal request through the Federal IDR portal pauses the Federal 
IDR process for 5 business days or until the non-initiating party 
responds, whichever happens first. If the non-initiating party fails to 
respond within 5 business days of the initiating party's request, the 
non-initiating party will be considered to have agreed to the 
withdrawal, and the dispute will be withdrawn;
    (C) The certified IDR entity cannot determine eligibility, for 
example, because both parties to the dispute are nonresponsive to any 
requests for additional information to determine eligibility as 
described in paragraph (c)(2)(ii) of this section; or
    (D) The certified IDR entity cannot make a payment determination, 
for example, because both parties to the dispute have failed to submit 
an offer as described in paragraph (c)(5)(i) of this section.
    (4) Treatment of batched qualified IDR items and services--(i) In 
general. For purposes of encouraging efficiencies (including minimizing 
costs) in the Federal IDR process, a certified IDR entity may consider 
up to 50 qualified IDR items and services jointly as part of a single 
payment determination that is subject to the certified IDR entity fee 
for batched disputes, only if the qualified IDR items and services meet 
the requirements of this paragraph (c)(4)(i):
    (A) The qualified IDR items and services are billed by the same 
provider or group of providers, the same facility, or the same provider 
of air ambulance services. Items and services are billed by the same 
provider or group of providers, the same facility, or the same provider 
of air ambulance services if the items or services are billed with the 
same National Provider Identifier or Tax Identification Number;
    (B) Payment for the qualified IDR items and services is required to 
be made by the same group health plan or health insurance issuer. For 
group or individual health insurance coverage, this requirement is 
satisfied if the same issuer is required to make payment for the 
qualified IDR items and services, even if the qualified IDR items and 
services relate to claims from different group health plans or 
individual market policies. For self-insured group health plans, this 
requirement is satisfied if the same self-insured group health plan is 
required to make payment for the qualified IDR items and services, 
including when the plan makes payments through a third party 
administrator; the requirement is not satisfied if multiple self-
insured group health plans are required to make payments for the 
qualified IDR items and services, even if those group health plans make 
payments through the same third party administrator;
    (C) The qualified IDR items and services meet any of the following 
criteria under which multiple qualified IDR items and services relate 
to the treatment of a similar condition:
    (1) The qualified IDR items or services were furnished to a single 
patient during a single patient encounter. For purposes of this 
section, a single patient encounter is defined as a patient encounter 
on one or more consecutive days during which the qualified IDR items or 
services were furnished to the same patient and billed on the same 
claim form; or
    (2) The qualified IDR items and services were furnished to one or 
more patients and were billed under the same service code or a 
comparable code under a different procedural coding system, such as 
Current Procedural Terminology (CPT) codes with modifiers, if 
applicable, Healthcare Common Procedure Coding System (HCPCS) codes 
with modifiers, if applicable, or Diagnosis-Related Group (DRG) codes 
with modifiers, if applicable; or
    (3) For anesthesiology, radiology, pathology, and laboratory 
qualified IDR items and services, the qualified IDR items and services 
were furnished to one or more patients and were billed under service 
codes belonging to the same Category I CPT code range, as specified in 
guidance published by the Secretary; and
    (D) All the qualified IDR items and services were furnished within 
the same 30-business-day period following the date on which the first 
item or service included in the batched dispute was furnished, and the 
qualified IDR items and services were the subjects of a 30-business-day 
open negotiation period that ended within 4 business days of IDR 
initiation, except as provided in paragraph (c)(5)(vii)(B) of this 
section.
    (ii) Treatment of bundled payment arrangements. Qualified IDR items 
and services that meet the definition of a bundled payment arrangement 
under Sec.  149.30 may be submitted and considered as a single payment 
determination, and the certified IDR entity must make a single payment 
determination for the multiple qualified IDR items and services 
included in the bundled payment arrangement. Bundled payment 
arrangements as defined in Sec.  149.30 and submitted under this 
paragraph (c)(4)(ii) are subject to the certified IDR entity fee for 
single determinations.
    (5) Payment determination for a qualified IDR item or service--(i) 
Submission of offers. Not later than 10 business days after the date of 
final selection of the certified IDR entity as described in paragraph 
(c)(1)(iv)(C) of this section (or not later than 10 business days after 
the qualified IDR items and services are determined eligible as 
described in paragraph (c)(2) of this section, when the Secretary 
determines that any of the extenuating circumstances described in 
paragraph (g)(1)(ii) of this section apply), the plan or issuer and the 
provider, facility, or provider of air ambulance services:
    (A) Must each submit to the certified IDR entity:
    (1) An offer of an out-of-network rate expressed as both a dollar 
amount and the corresponding percentage of the qualifying payment 
amount represented by that dollar amount.
    (2) Information requested by the certified IDR entity relating to 
the offer.
    (3) The following additional information, as applicable--
    (i) For providers and facilities, information on the size of the 
provider's practice or of the facility (if applicable). Specifically, a 
group of providers must specify whether the providers' practice has 
fewer than 20 employees, 20 to 50 employees, 51 to 100 employees, 101 
to 500 employees, or more than 500 employees. For facilities, the 
facility must specify whether the facility has 50 or fewer employees, 
51 to 100 employees, 101 to 500 employees, or more than 500 employees;

[[Page 55472]]

    (ii) For providers and facilities, information on the practice 
specialty or type, respectively (if applicable);
    (iii) For plans and issuers, information on the coverage area of 
the plan or issuer, the relevant geographic region for purposes of the 
qualifying payment amount, whether the coverage is fully-insured or 
partially or fully self-insured (or a FEHB carrier if the item or 
service relates to FEHB plans); and
    (iv) The qualifying payment amount for the applicable year for the 
same or similar item or service as the qualified IDR item or service.
    (B) May each submit to the certified IDR entity any information 
relating to the offer that was submitted by either party, except that 
the information may not include information on factors described in 
paragraph (c)(5)(v) of this section.
    (ii) Payment determination and notification. Not later than 30 
business days after the date of final selection of the certified IDR 
entity as described in paragraph (c)(1)(iv)(C) of this section (or not 
later than 30 business days after the qualified IDR items and services 
are determined eligible as described in paragraph (c)(2) of this 
section, when the Secretary determines that any of the extenuating 
circumstances described in paragraph (g) of this section apply), the 
certified IDR entity must:
    (A) Select as the out-of-network rate for the qualified IDR item or 
service one of the offers submitted under paragraph (c)(5)(i) of this 
section, weighing only the considerations specified in paragraph 
(c)(5)(iii) of this section (as applied to the information provided by 
the parties pursuant to 29 CFR 2590.716-8(c)(5)(i). The certified IDR 
entity must select the offer that the certified IDR entity determines 
best represents the value of the qualified IDR item or service as the 
out-of-network rate.
    (1) Prevailing party. In the case of single determinations, the 
party whose offer is selected by the certified IDR entity is considered 
the prevailing party. In the case of batched determinations, the party 
with the most determinations in its favor is considered the prevailing 
party.
    (2) Non-prevailing party. In the case of single determinations, the 
party whose offer is not selected by the certified IDR entity is 
considered the non-prevailing party. In the case of batched 
determinations, the party with the fewest determinations in its favor 
is considered the non-prevailing party.
    (3) Parties prevailing in equal numbers of determinations. If each 
party prevails in an equal number of determinations, neither party will 
be considered the prevailing party or the non-prevailing party, and the 
certified IDR entity fee will be split evenly between the parties.
    (B) Notify the plan or issuer and the provider or facility, as 
applicable, of the selection of the offer under paragraph (c)(5)(ii)(A) 
of this section, and provide the written decision required under 
paragraph (c)(5)(vi) of this section.
    (iii) Considerations in determination. In determining which offer 
to select:
    (A) The certified IDR entity must consider the qualifying payment 
amount(s) for the applicable year for the same or similar item or 
service.
    (B) The certified IDR entity must consider information submitted by 
a party that relates to the following circumstances:
    (1) The level of training, experience, and quality and outcomes 
measurements of the provider or facility that furnished the qualified 
IDR item or service (such as those endorsed by the consensus-based 
entity authorized in section 1890 of the Social Security Act).
    (2) The market share held by the provider or facility or that of 
the plan or issuer in the geographic region in which the qualified IDR 
item or service was provided.
    (3) The acuity of the participant, beneficiary, or enrollee 
receiving the qualified IDR item or service, or the complexity of 
furnishing the qualified IDR item or service to the participant, 
beneficiary, or enrollee.
    (4) The teaching status, case mix, and scope of services of the 
facility that furnished the qualified IDR item or service, if 
applicable.
    (5) Demonstration of good faith efforts (or lack thereof) made by 
the provider or facility or the plan or issuer to enter into network 
agreements with each other, and, if applicable, contracted rates 
between the provider or facility, as applicable, and the plan or 
issuer, as applicable, during the previous 4 plan years.
    (C) The certified IDR entity must also consider information 
provided by a party in response to a request by the certified IDR 
entity under paragraph (c)(5)(i)(A)(2) of this section that relates to 
the offer for the payment amount for the qualified IDR item or service 
that is the subject of the payment determination and that does not 
include information on factors described in paragraph (c)(5)(v) of this 
section.
    (D) The certified IDR entity must also consider additional 
information submitted by a party that relates to the offer for the 
payment amount for the qualified IDR item or service that is the 
subject of the payment determination and that does not include 
information on factors described in paragraph (c)(5)(v) of this 
section.
    (iv) [Reserved]
    (v) Prohibition on consideration of certain factors. In determining 
which offer to select, the certified IDR entity must not consider:
    (A) Usual and customary charges (including payment or reimbursement 
rates expressed as a proportion of usual and customary charges);
    (B) The amount that would have been billed by the provider or 
facility for the qualified IDR item or service had the provisions of 
Sec. Sec.  149.410 and 149.420 (as applicable) not applied; or
    (C) The payment or reimbursement rate for items and services 
furnished by the provider or facility payable by a public payor, 
including under the Medicare program under title XVIII of the Social 
Security Act; the Medicaid program under title XIX of the Social 
Security Act; the Children's Health Insurance Program under title XXI 
of the Social Security Act; the TRICARE program under chapter 55 of 
title 10, United States Code; chapter 17 of title 38, United States 
Code; or demonstration projects under section 1115 of the Social 
Security Act.
    (vi) Written decision. (A) The certified IDR entity must explain 
its determination in a written decision submitted to the parties and 
the Secretary, in a form and manner specified by the Secretary.
    (B) The certified IDR entity's written decision must include an 
explanation of their determination, including what information the 
certified IDR entity determined demonstrated that the offer selected as 
the out-of-network rate is the offer that best represents the value of 
the qualified IDR item or service, including the weight given to the 
qualifying payment amount and any additional credible information under 
paragraphs (c)(5)(iii)(B) through (D) of this section.
    (vii) Effects of determination--(A) Binding. A determination made 
by a certified IDR entity under paragraph (c)(5)(ii) of this section:
    (1) Is binding upon the parties, in the absence of fraud or 
evidence of intentional misrepresentation of material facts presented 
to the certified IDR entity regarding the claim; and
    (2) Is not subject to judicial review, except in a case described 
in any of paragraphs (1) through (4) of section 10(a) of title 9, 
United States Code.
    (B) Suspension of certain subsequent IDR requests. In the case of a 
single determination made by a certified IDR entity under paragraph 
(c)(5)(ii) of this section, the party that submitted the initial 
notification under paragraph (b)(2) of this section may not submit a

[[Page 55473]]

subsequent notification involving the same other party for a claim for 
the same item or service that was the subject of the initial 
notification during the 90-calendar-day period following the 
determination. In the case of a batched determination made by a 
certified IDR entity under paragraph (c)(5)(ii) of this section, the 
party that submitted the initial notification under paragraph (b)(2) of 
this section may not submit a subsequent notification involving the 
same other party for a claim for the same items or services that were 
the subject of the initial notification during the 30-business-day 
period following the determination.
    (C) Subsequent submission of requests permitted. In the case of a 
single determination made by a certified IDR entity under paragraph 
(c)(5)(ii) of this section, if the end of the open negotiation period 
specified in paragraph (b)(1) of this section occurs during the 90-
calendar-day suspension period regarding claims for the same item or 
service that were the subject of the single determination, either party 
may initiate the Federal IDR process for those claims by submitting a 
notification as specified in paragraph (b)(2) of this section during 
the 30-business-day period beginning on the day after the last day of 
the 90-calendar-day suspension period. In the case of a batched 
determination made by a certified IDR entity under paragraph (c)(5)(ii) 
of this section, if the end of the open negotiation period specified in 
paragraph (b)(1) of this section is completed in the 30 business days 
prior to or during the 30-business-day suspension period regarding 
claims for the same items or services that were the subject of the 
batched determination, either party may initiate the Federal IDR 
process for those claims by submitting a notification as specified in 
paragraph (b)(2) of this section during the 4-business-day period 
beginning on the business day after the 30-business-day suspension 
period as described in paragraph (c)(5)(vii)(B) of this section.
    (viii) Recordkeeping requirements. The certified IDR entity must 
maintain records of all claims and notices associated with the Federal 
IDR process with respect to any determination for 6 years. The 
certified IDR entity must make these records available for examination 
by the plan, issuer, FEHB carrier, provider, facility, or provider of 
air ambulance services, or a State or Federal oversight agency upon 
request, except to the extent the disclosure would violate either State 
or Federal privacy law.
    (ix) Payment. If applicable, the amount of the offer selected by 
the certified IDR entity (less the sum of the initial payment and any 
cost sharing paid or owed by the participant or beneficiary) must be 
paid directly to the provider, facility, or provider of air ambulance 
services not later than 30 calendar days after the determination by the 
certified IDR entity. If the offer selected by the certified IDR entity 
is less than the sum of the initial payment and any cost sharing paid 
by the participant or beneficiary, the provider, facility, or provider 
of air ambulance services will be liable to the plan or issuer for the 
difference. The provider, facility, or provider of air ambulance 
services must pay the difference directly to the plan or issuer not 
later than 30 calendar days after the determination by the certified 
IDR entity.

Liesl I. Fowler,
Executive Secretary to the Department, Department of Health and Human 
Services.

Daniel Aronowitz,
Assistant Secretary, Employee Benefits Security Administration, 
Department of Labor.

Kalle L. Wardlow,
Federal Register Liaison, Publications and Regulations, Associate Chief 
Counsel, (Procedure and Administration) Department of the Treasury.

In concurrence:

Kurt D. Dykstra,
General Counsel, Office of Personnel Management.
[FR Doc. 2026-17622 Filed 8-27-26; 8:45 am]
BILLING CODE 6325-63-P; 4831-GV-P; 4510-29-P; 4169-69-P


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