Non Emergency Services Independent Dispute Resolution Process

Legislation enacted in 2016 (AB 72), protects consumers from “surprise” balance-bills for non-emergency services. AB 72 requires health plans and entities delegated payment function by health plans (“payors”) to reimburse noncontracting individual health professionals (“noncontracting providers”) at a specified rate for services rendered at, or as a result of services rendered at, a contracting facility. The law requires the DMHC to conduct an independent dispute resolution process (AB 72 IDRP) that allows a noncontracting provider or payor to dispute whether payment of the specified rate was appropriate. The law also requires the DMHC to establish the AB 72 Uniform Written Procedures and Guidelines for the submission, receipt, processing, and resolution of claims submitted to the AB 72 IDRP.

Once a noncontracting provider or payor submits an AB 72 IDRP Application, the opposing party is required by law to participate in the AB 72 IDRP. AB 72 does not apply to emergency services and care, dental providers, or to Medi-Cal managed care plans. AB 72 authorizes the DMHC to contract with one or more independent organizations to conduct the AB 72 IDRP. The decision of the independent organization is binding on the parties, but after completing the AB 72 IDRP, a dissatisfied party may pursue any right, remedy, or penalty established under any other applicable law. The AB 72 IDRP is conducted electronically through a web-based portal that is managed by MAXIMUS Federal Services, Inc. (MAXIMUS), the independent organization currently conducting the AB 72 IDRP.

Do I Qualify?

Noncontracting providers and payors that dispute the appropriateness of the amount received or paid for non-emergency services most commonly subject to Health and Safety Code Section 1371.9 may be eligible to submit an AB 72 IDRP Application.

Noncontracting providers and payors may request independent review through the AB 72 IDRP for an individual claim or multiple claims (up to 50) involving the same or similar services, same noncontracting provider and the same health care service plan.

If you are a provider and these parameters do not apply to you, you may still be eligible for the DMHC’s Emergency Services IDRP, or you may be able to file a Complaint Against a Plan.

Eligible Claims

Eligible claim disputes are those disputes that are subject to DMHC jurisdiction and meet all of the following criteria:

• The disputed claim must be for services rendered on or after July 1, 2017.
• The disputed claim must be for non-emergency services. If there is an unresolved dispute as to whether the health care service(s) at issue is non-emergent, the claim does not qualify for the AB 72 IDRP.
• The disputed claim must be for covered services provided at a contracting health facility, or provided as a result of covered services at a contracting health facility, by a noncontracting individual health professional.
• The noncontracting provider has completed the health plan or payor’s Provider Dispute Resolution (PDR) process within the last 365 days.
• The noncontracting provider is not a dentist.
• The payor is not a Medi-Cal managed health care service plan or any other entity that enters into a contract with the State Department of Health Care Services.

Ineligible Claims

Claim disputes that do not meet all of the criteria listed above, including disputes concerning claims that have not been submitted to (and completed) the health plan or payor’s Provider Dispute Resolution (PDR) process, are ineligible for the AB72 IDRP. This includes:

• Claim disputes that are not subject to DMHC jurisdiction.
• Late payment disputes.
• Interest payment disputes.
• Disputes concerning emergency services or the level of care provided.
• Claim disputes with health plans licensed or regulated by another state.
• Disputes regarding claims that do not involve covered benefits.
• Claims denied on the basis that the services were not medically necessary or were experimental/investigational in nature.

Steps for Filing

Upon submission of a complete AB 72 IDRP Application through the web-based portal, the DMHC will review the submission and then, if the submitter is a noncontracting provider, contact the health plan to confirm DMHC jurisdiction and identify the responsible payor. Once DMHC jurisdiction is confirmed and both parties to the AB 72 IDRP are clearly identified, the opposing party will have a full opportunity to submit any information and/or documents relevant to the reimbursement amount for the claim(s) at issue. After the DMHC confirms that the claim(s) dispute meets the requirements for the AB72 IDRP, the claim(s) dispute will be forwarded to the independent organization for review.

The following documents must be included with an IDRP Application in order for it to be processed by the DMHC:

• Claim Form(s)
• Provider Dispute Resolution (PDR) Determination Letter(s)
  Note: If a provider attempted PDR, but did not receive an acknowledgment letter or determination letter from the payor and at least 45 business days have passed since the date of receipt of the provider dispute, the provider may submit dated proof of the PDR attempt in lieu of a PDR determination letter.
• Explanation(s) of Benefits or Remittance Advice

About the Decision Process

• the provider’s training, qualifications, and length of time in practice;
• the nature of the services provided;
• the fees usually charged by the provider;
• prevailing provider rates charged in the general geographic area in which the services were rendered;
• other aspects of the economics of the medical provider’s practice that are relevant; and
• any unusual circumstances in the case.

The AB 72 IDRP decision drafted by the independent organization will provide a written explanation of the appropriate reimbursement amount decision, and will include a list of appropriate reimbursement amounts by relevant billing code. The independent organization is not limited to the suggested appropriate reimbursement amounts offered by each party when making its decision.

Independent Review Rate Schedule

The review fees for the AB 72 IDRP are split equally between the parties. Review fees are billed and collected solely by the independent organization conducting the AB 72 IDRP. Review fees will be collected before the independent organization begins reviewing a claim(s) dispute and prior to the issuance of an AB 72 IDRP Decision Letter.

AB 72 IDRP review fees increase based on the number of claims bundled within a claim(s) dispute. A list of current AB 72 IDRP review fees is as follows:

AB 72 Independent Dispute Resolution Process Quarterly Reports

The Provider Complaint Unit tracks the number of IDRP applications received and processed by the Department on a quarterly basis.