Here are three things you should be aware of:
1. If a qualifying payment amount is based on a down coded service code or modifier, a plan or issuer must provide with its initial payment:
· A statement that the service code or modifier billed by the provider, or facility was down coded.
· An explanation of why the claim was down coded, including a description of which service codes or modifiers were altered, added or removed, if any.
· The amount that would have been the qualifying payment amount had the service code or modifier not been down coded.
2. Certified independent dispute resolution entities must consider the qualifying payment amount and then must consider all additional permissible information submitted by each party to determine which offer best reflects the appropriate out-of-network rate. After weighing these considerations, independent dispute resolution entities should then select the offer that "best represents the value of the item or service under the dispute."
3. The final rule finalizes early provisions requiring independent dispute resolution entities to explain their payment determinations and underlying rationale in a written decision submitted to the parties, HHS and the Labor Department.