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CMS Clarifies Batching Rules: Eligibility Extends Through 90-Day Cooling-Off Period

CMS Clarifies Batching Rules: Eligibility Extends Through 90-Day Cooling-Off Period
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As part of ongoing efforts by FHAS to provide much-needed clarity to payers and providers about the Independent Dispute Resolution (IDR) process, we recently reached out to the Centers for Medicare & Medicaid Services (CMS) for additional guidance on batching eligibility.

Specifically, we wanted to determine if disputes where the items and services were furnished during the 90-day period following the date on which the first item or service included in the batched determination was furnished could be batched for IDR.

According to CMS, this is allowed. Items and services furnished during the 90-day cooling off period are eligible to be batched together. Previously, all batched items and services needed to have occurred during a 30-business day period following the date on which the earliest included item or service was furnished.

Batching Eligibility Can Extend to 90 Days

Based on the clarification, if a claim is impacted by the cooling-off period, providers can batch all other services impacted that occurred during that time period together once cooling-off concludes. Additional batching rules remain unchanged and must still be followed.

Under this new guidance, if a provider can show that claims experienced a cooling off period, they can submit batches that have a span of up to 90 days from the first to last date of service, rather than 30 days.

CMS Evidence for Guidance

CMS directed FHAS to the following information regarding the No Surprises Act to support the extension batching through the cooling-off period:

Requirements Related to Surprise Billing; Part II (at 55994, emphasis added):

Therefore, if items or services are furnished within the 90-calendar-day suspension period and meet the other applicable requirements, they may be submitted and considered jointly as part of one payment determination by a certified IDR entity, once the suspension period has ended. Under Code section 9816(c)(9), ERISA section 716(c)(9), and PHS Act section 2799A1(c)(9), the Departments may provide an alternative period to the aforementioned 30-business-day period as determined by the Departments for certain circumstances, such as low-volume items and services. The Departments are using this authority to ensure that items and services delivered during the 90-calendar-day suspension period are eligible for the Federal IDR process and may be included in the same batch.


Additionally, CMS directed us to this language in the Code of Federal Regulations and the IDR Process Guidance:

45 CFR 149.510(c)(3):
45 CFR 149.510(c)(4)(vii)(C)
Federal IDR Process Guidance for Disputing Parties (at 8.3)

 

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