H. R. 133—1616 
(1) APPLICATION TO FEHB.—Section 8902 of title 5, United 
States Code, is amended by adding at the end the following 
new subsection: 
‘‘(p) Each contract under this chapter shall require the carrier 
to comply with requirements described in the provisions of sections 
2799A–1, 2799A–2, and 2799A–7 of the Public Health Service Act, 
sections 716, 717, and 722 of the Employee Retirement Income 
Security Act of 1974, and sections 9816, 9817, and 9822 of the 
Internal Revenue Code of 1986 (as applicable) in the same manner 
as such provisions apply to a group health plan or health insurance 
issuer offering group or individual health insurance coverage, as 
described in such sections. The provisions of sections 2799B–1, 
2799B–2, 2799B–3, and 2799B–5 of the Public Health Service Act 
shall apply to a health care provider and facility and an air ambu-
lance provider described in such respective sections with respect 
to an enrollee in a health benefits plan under this chapter in 
the same manner as such provisions apply to such a provider 
and facility with respect to an enrollee in a group health plan 
or group or individual health insurance coverage offered by a health 
insurance issuer, as described in such sections.’’. 
(2) APPLICATION
TO
GRANDFATHERED
PLANS.—Section 
1251(a) of the Patient Protection and Affordable Care Act (42 
U.S.C. 18011(a)) is amended by adding at the end the following: 
‘‘(5) APPLICATION
OF
ADDITIONAL
PROVISIONS.—Sections 
2799A–1, 2799A–2, and 2799A–7 of the Public Health Service 
Act shall apply to grandfathered health plans for plan years 
beginning on or after January 1, 2022.’’. 
(3) RULE
OF
CONSTRUCTION.—Nothing in this title, 
including the amendments made by this title may be construed 
as modifying, reducing, or eliminating— 
(A) the protections under section 222 of the Indian 
Health Care Improvement Act (25 U.S.C. 1621u) and under 
subpart I of part 136 of title 42, Code of Federal Regula-
tions (or any successor regulation), against payment 
liability for a patient who receives contract health services 
that are authorized by the Indian Health Service; or 
(B) the requirements under section 1866(a)(1)(U) of 
the Social Security Act (42 U.S.C. 1395cc(a)(1)(U)). 
(e) EFFECTIVE DATE.—The amendments made by this section 
shall apply with respect to plan years (or, in the case of the 
amendment made by subsection (d)(1), with respect to contracts 
entered into or renewed for contract years) beginning on or after 
January 1, 2022. 
SEC. 103. DETERMINATION OF OUT-OF-NETWORK RATES TO BE PAID 
BY HEALTH PLANS; INDEPENDENT DISPUTE RESOLU-
TION PROCESS. 
(a) PHSA.—Section 2799A–1, as added by section 102, is 
amended— 
(1) by redesignating subsection (c) as subsection (d); and 
(2) by inserting after subsection (b) the following new sub-
section: 
‘‘(c) DETERMINATION OF OUT-OF-NETWORK RATES TO BE PAID 
BY HEALTH PLANS; INDEPENDENT DISPUTE RESOLUTION PROCESS.— 
‘‘(1) DETERMINATION THROUGH OPEN NEGOTIATION.— 
‘‘(A) IN GENERAL.—With respect to an item or service 
furnished in a year by a nonparticipating provider or a
H. R. 133—1617 
nonparticipating facility, with respect to a group health 
plan or health insurance issuer offering group or individual 
health insurance coverage, in a State described in sub-
section (a)(3)(K)(ii) with respect to such plan or coverage 
and provider or facility, and for which a payment is 
required to be made by the plan or coverage pursuant 
to subsection (a)(1) or (b)(1), the provider or facility (as 
applicable) or plan or coverage may, during the 30-day 
period beginning on the day the provider or facility receives 
an initial payment or a notice of denial of payment from 
the plan or coverage regarding a claim for payment for 
such item or service, initiate open negotiations under this 
paragraph between such provider or facility and plan or 
coverage for purposes of determining, during the open nego-
tiation period, an amount agreed on by such provider or 
facility, respectively, and such plan or coverage for payment 
(including any cost-sharing) for such item or service. For 
purposes of this subsection, the open negotiation period, 
with respect to an item or service, is the 30-day period 
beginning on the date of initiation of the negotiations with 
respect to such item or service. 
‘‘(B) ACCESSING
INDEPENDENT
DISPUTE
RESOLUTION 
PROCESS IN CASE OF FAILED NEGOTIATIONS.—In the case 
of open negotiations pursuant to subparagraph (A), with 
respect to an item or service, that do not result in a 
determination of an amount of payment for such item 
or service by the last day of the open negotiation period 
described in such subparagraph with respect to such item 
or service, the provider or facility (as applicable) or group 
health plan or health insurance issuer offering group or 
individual health insurance coverage that was party to 
such negotiations may, during the 4-day period beginning 
on the day after such open negotiation period, initiate 
the independent dispute resolution process under para-
graph (2) with respect to such item or service. The inde-
pendent dispute resolution process shall be initiated by 
a party pursuant to the previous sentence by submission 
to the other party and to the Secretary of a notification 
(containing such information as specified by the Secretary) 
and for purposes of this subsection, the date of initiation 
of such process shall be the date of such submission or 
such other date specified by the Secretary pursuant to 
regulations that is not later than the date of receipt of 
such notification by both the other party and the Secretary. 
‘‘(2) INDEPENDENT DISPUTE RESOLUTION PROCESS AVAILABLE 
IN CASE OF FAILED OPEN NEGOTIATIONS.— 
‘‘(A) ESTABLISHMENT.—Not later than 1 year after the 
date of the enactment of this subsection, the Secretary, 
jointly with the Secretary of Labor and the Secretary of 
the Treasury, shall establish by regulation one independent 
dispute resolution process (referred to in this subsection 
as the ‘IDR process’) under which, in the case of an item 
or service with respect to which a provider or facility (as 
applicable) or group health plan or health insurance issuer 
offering group or individual health insurance coverage sub-
mits a notification under paragraph (1)(B) (in this sub-
section referred to as a ‘qualified IDR item or service’),
H. R. 133—1618 
a certified IDR entity under paragraph (4) determines, 
subject to subparagraph (B) and in accordance with the 
succeeding provisions of this subsection, the amount of 
payment under the plan or coverage for such item or service 
furnished by such provider or facility. 
‘‘(B) AUTHORITY TO CONTINUE NEGOTIATIONS.—Under 
the independent dispute resolution process, in the case 
that the parties to a determination for a qualified IDR 
item or service agree on a payment amount for such item 
or service during such process but before the date on which 
the entity selected with respect to such determination 
under paragraph (4) makes such determination under para-
graph (5), such amount shall be treated for purposes of 
subsection (a)(3)(K)(ii) as the amount agreed to by such 
parties for such item or service. In the case of an agreement 
described in the previous sentence, the independent dispute 
resolution process shall provide for a method to determine 
how to allocate between the parties to such determination 
the payment of the compensation of the entity selected 
with respect to such determination. 
‘‘(C) CLARIFICATION.—A nonparticipating provider may 
not, with respect to an item or service furnished by such 
provider, submit a notification under paragraph (1)(B) if 
such provider is exempt from the requirement under sub-
section (a) of section 2799B–2 with respect to such item 
or service pursuant to subsection (b) of such section. 
‘‘(3) TREATMENT OF BATCHING OF ITEMS AND SERVICES.— 
‘‘(A) IN GENERAL.—Under the IDR process, the Sec-
retary shall specify criteria under which multiple qualified 
IDR dispute items and services are permitted to be consid-
ered jointly as part of a single determination by an entity 
for purposes of encouraging the efficiency (including mini-
mizing costs) of the IDR process. Such items and services 
may be so considered only if— 
‘‘(i) such items and services to be included in such 
determination are furnished by the same provider or 
facility; 
‘‘(ii) payment for such items and services is 
required to be made by the same group health plan 
or health insurance issuer; 
‘‘(iii) such items and services are related to the 
treatment of a similar condition; and 
‘‘(iv) such items and services were furnished during 
the 30 day period following the date on which the 
first item or service included with respect to such 
determination was furnished or an alternative period 
as determined by the Secretary, for use in limited 
situations, such as by the consent of the parties or 
in the case of low-volume items and services, to encour-
age procedural efficiency and minimize health plan 
and provider administrative costs. 
‘‘(B) TREATMENT OF BUNDLED PAYMENTS.—In carrying 
out subparagraph (A), the Secretary shall provide that, 
in the case of items and services which are included by 
a provider or facility as part of a bundled payment, such 
items and services included in such bundled payment may 
be part of a single determination under this subsection.
H. R. 133—1619 
‘‘(4) CERTIFICATION AND SELECTION OF IDR ENTITIES.— 
‘‘(A) IN GENERAL.—The Secretary, in consultation with 
the Secretary of Labor and Secretary of the Treasury, shall 
establish a process to certify (including to recertify) entities 
under this paragraph. Such process shall ensure that an 
entity so certified— 
‘‘(i) has (directly or through contracts or other 
arrangements) sufficient medical, legal, and other 
expertise and sufficient staffing to make determina-
tions described in paragraph (5) on a timely basis; 
‘‘(ii) is not— 
‘‘(I) a group health plan or health insurance 
issuer offering group or individual health insur-
ance coverage, provider, or facility; 
‘‘(II) an affiliate or a subsidiary of such a group 
health plan or health insurance issuer, provider, 
or facility; or 
‘‘(III) an affiliate or subsidiary of a professional 
or trade association of such group health plans 
or health insurance issuers or of providers or facili-
ties; 
‘‘(iii) carries out the responsibilities of such an 
entity in accordance with this subsection; 
‘‘(iv) meets appropriate indicators of fiscal integ-
rity; 
‘‘(v) maintains the confidentiality (in accordance 
with regulations promulgated by the Secretary) of 
individually identifiable health information obtained 
in the course of conducting such determinations; 
‘‘(vi) does not under the IDR process carry out 
any determination with respect to which the entity 
would not pursuant to subclause (I), (II), or (III) of 
subparagraph (F)(i) be eligible for selection; and 
‘‘(vii) meets such other requirements as determined 
appropriate by the Secretary. 
‘‘(B) PERIOD OF CERTIFICATION.—Subject to subpara-
graph (C), each certification (including a recertification) 
of an entity under the process described in subparagraph 
(A) shall be for a 5-year period. 
‘‘(C) REVOCATION.—A certification of an entity under 
this paragraph may be revoked under the process described 
in subparagraph (A) if the entity has a pattern or practice 
of noncompliance with any of the requirements described 
in such subparagraph. 
‘‘(D) PETITION
FOR
DENIAL
OR
WITHDRAWAL.—The 
process described in subparagraph (A) shall ensure that 
an individual, provider, facility, or group health plan or 
health insurance issuer offering group or individual health 
insurance coverage may petition for a denial of a certifi-
cation or a revocation of a certification with respect to 
an entity under this paragraph for failure of meeting a 
requirement of this subsection. 
‘‘(E) SUFFICIENT
NUMBER
OF
ENTITIES.—The process 
described in subparagraph (A) shall ensure that a sufficient 
number of entities are certified under this paragraph to 
ensure the timely and efficient provision of determinations 
described in paragraph (5).
H. R. 133—1620 
‘‘(F) SELECTION OF CERTIFIED IDR ENTITY.—The Sec-
retary shall, with respect to the determination of the 
amount of payment under this subsection of an item or 
service, provide for a method— 
‘‘(i) that allows for the group health plan or health 
insurance issuer offering group or individual health 
insurance coverage and the nonparticipating provider 
or 
the 
nonparticipating 
emergency 
facility 
(as 
applicable) involved in a notification under paragraph 
(1)(B) to jointly select, not later than the last day 
of the 3-business day period following the date of the 
initiation of the process with respect to such item 
or service, for purposes of making such determination, 
an entity certified under this paragraph that— 
‘‘(I) is not a party to such determination or 
an employee or agent of such a party; 
‘‘(II) does not have a material familial, finan-
cial, or professional relationship with such a party; 
and 
‘‘(III) does not otherwise have a conflict of 
interest with such a party (as determined by the 
Secretary); and 
‘‘(ii) that requires, in the case such parties do 
not make such selection by such last day, the Secretary 
to, not later than 6 business days after such date 
of initiation— 
‘‘(I) select such an entity that satisfies sub-
clauses (I) through (III) of clause (i)); and 
‘‘(II) provide notification of such selection to 
the provider or facility (as applicable) and the plan 
or issuer (as applicable) party to such determina-
tion. 
An entity selected pursuant to the previous sentence to make a 
determination described in such sentence shall be referred to in 
this subsection as the ‘certified IDR entity’ with respect to such 
determination. 
‘‘(5) PAYMENT DETERMINATION.— 
‘‘(A) IN GENERAL.—Not later than 30 days after the 
date of selection of the certified IDR entity with respect 
to a determination for a qualified IDR item or service, 
the certified IDR entity shall— 
‘‘(i) taking into account the considerations specified 
in subparagraph (C), select one of the offers submitted 
under subparagraph (B) to be the amount of payment 
for such item or service determined under this sub-
section for purposes of subsection (a)(1) or (b)(1), as 
applicable; and 
‘‘(ii) notify the provider or facility and the group 
health plan or health insurance issuer offering group 
or individual health insurance coverage party to such 
determination of the offer selected under clause (i). 
‘‘(B) SUBMISSION OF OFFERS.—Not later than 10 days 
after the date of selection of the certified IDR entity with 
respect to a determination for a qualified IDR item or 
service, the provider or facility and the group health plan 
or health insurance issuer offering group or individual 
health insurance coverage party to such determination—
H. R. 133—1622 
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. 
‘‘(D) PROHIBITION ON CONSIDERATION OF CERTAIN FAC-
TORS.—In determining which offer is the payment to be 
applied with respect to qualified IDR items and services 
furnished by a provider or facility, the certified IDR entity 
with respect to a determination shall not consider usual 
and customary charges, the amount that would have been 
billed by such provider or facility with respect to such 
items and services had the provisions of section 2799B– 
1 or 2799B–2 (as applicable) not applied, or the payment 
or reimbursement rate for such items and services fur-
nished by such provider or facility payable by a public 
payor, including under the Medicare program under title 
XVIII of the Social Security Act, under the Medicaid pro-
gram under title XIX of such Act, under the Children’s 
Health Insurance Program under title XXI of such Act, 
under the TRICARE program under chapter 55 of title 
10, United States Code, or under chapter 17 of title 38, 
United States Code. 
‘‘(E) EFFECTS OF DETERMINATION.— 
‘‘(i) IN GENERAL.—A determination of a certified 
IDR entity under subparagraph (A)— 
‘‘(I) shall be binding upon the parties involved, 
in the absence of a fraudulent claim or evidence 
of misrepresentation of facts presented to the IDR 
entity involved regarding such claim; and 
‘‘(II) shall not be 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. 
‘‘(ii) SUSPENSION
OF
CERTAIN
SUBSEQUENT
IDR 
REQUESTS.—In the case of a determination of a certified 
IDR entity under subparagraph (A), with respect to 
an initial notification submitted under paragraph (1)(B) 
with respect to qualified IDR items and services and 
the two parties involved with such notification, the 
party that submitted such notification may not submit 
during the 90-day period following such determination 
a subsequent notification under such paragraph 
involving the same other party to such notification 
with respect to such an item or service that was the 
subject of such initial notification. 
‘‘(iii) SUBSEQUENT SUBMISSION OF REQUESTS PER-
MITTED.—In the case of a notification that pursuant 
to clause (ii) is not permitted to be submitted under 
paragraph (1)(B) during a 90-day period specified in 
such clause, if the end of the open negotiation period 
specified in paragraph (1)(A), that but for this clause 
would otherwise apply with respect to such notification, 
occurs during such 90-day period, such paragraph 
(1)(B) shall be applied as if the reference in such para-
graph to the 4-day period beginning on the day after 
such open negotiation period were instead a reference
H. R. 133—1623 
to the 30-day period beginning on the day after the 
last day of such 90-day period. 
‘‘(iv) REPORTS.—The Secretary, jointly with the 
Secretary of Labor and the Secretary of the Treasury, 
shall examine the impact of the application of clause 
(ii) and whether the application of such clause delays 
payment determinations or impacts early, alternative 
resolution of claims (such as through open negotia-
tions), and shall submit to Congress, not later than 
2 years after the date of implementation of such clause 
an interim report (and not later than 4 years after 
such date of implementation, a final report) on whether 
any group health plans or health insurance issuers 
offering group or individual health insurance coverage 
or types of such plans or coverage have a pattern 
or practice of routine denial, low payment, or down- 
coding of claims, or otherwise abuse the 90-day period 
described in such clause, including recommendations 
on ways to discourage such a pattern or practice. 
‘‘(F) COSTS
OF
INDEPENDENT
DISPUTE
RESOLUTION 
PROCESS.—In the case of a notification under paragraph 
(1)(B) submitted by a nonparticipating provider, nonpartici-
pating emergency facility, group health plan, or health 
insurance issuer offering group or individual health insur-
ance coverage and submitted to a certified IDR entity— 
‘‘(i) if such entity makes a determination with 
respect to such notification under subparagraph (A), 
the party whose offer is not chosen under such subpara-
graph shall be responsible for paying all fees charged 
by such entity; and 
‘‘(ii) if the parties reach a settlement with respect 
to such notification prior to such a determination, each 
party shall pay half of all fees charged by such entity, 
unless the parties otherwise agree. 
‘‘(6) TIMING OF PAYMENT.—The total plan or coverage pay-
ment required pursuant to subsection (a)(1) or (b)(1), with 
respect to a qualified IDR item or service for which a determina-
tion is made under paragraph (5)(A) or with respect to an 
item or service for which a payment amount is determined 
under open negotiations under paragraph (1), shall be made 
directly to the nonparticipating provider or facility not later 
than 30 days after the date on which such determination is 
made. 
‘‘(7) PUBLICATION OF INFORMATION RELATING TO THE IDR 
PROCESS.— 
‘‘(A) PUBLICATION OF INFORMATION.—For each calendar 
quarter in 2022 and each calendar quarter in a subsequent 
year, the Secretary shall make available on the public 
website of the Department of Health and Human Services— 
‘‘(i) the number of notifications submitted under 
paragraph (1)(B) during such calendar quarter; 
‘‘(ii) the size of the provider practices and the 
size of the facilities submitting notifications under 
paragraph (1)(B) during such calendar quarter; 
‘‘(iii) the number of such notifications with respect 
to which a determination was made under paragraph 
(5)(A);
H. R. 133—1624 
‘‘(iv) the information described in subparagraph 
(B) with respect to each notification with respect to 
which such a determination was so made; 
‘‘(v) the number of times the payment amount 
determined (or agreed to) under this subsection exceeds 
the qualifying payment amount, specified by items and 
services; 
‘‘(vi) the amount of expenditures made by the Sec-
retary during such calendar quarter to carry out the 
IDR process; 
‘‘(vii) the total amount of fees paid under para-
graph (8) during such calendar quarter; and 
‘‘(viii) the total amount of compensation paid to 
certified IDR entities under paragraph (5)(F) during 
such calendar quarter. 
‘‘(B) INFORMATION.—For purposes of subparagraph (A), 
the information described in this subparagraph is, with 
respect to a notification under paragraph (1)(B) by a non-
participating provider, nonparticipating emergency facility, 
group health plan, or health insurance issuer offering group 
or individual health insurance coverage— 
‘‘(i) a description of each item and service included 
with respect to such notification; 
‘‘(ii) the geography in which the items and services 
with respect to such notification were provided; 
‘‘(iii) the amount of the offer submitted under para-
graph (5)(B) by the group health plan or health insur-
ance issuer (as applicable) and by the nonparticipating 
provider or nonparticipating emergency facility (as 
applicable) expressed as a percentage of the qualifying 
payment amount; 
‘‘(iv) whether the offer selected by the certified 
IDR entity under paragraph (5) to be the payment 
applied was the offer submitted by such plan or issuer 
(as applicable) or by such provider or facility (as 
applicable) and the amount of such offer so selected 
expressed as a percentage of the qualifying payment 
amount; 
‘‘(v) the category and practice specialty of each 
such provider or facility involved in furnishing such 
items and services; 
‘‘(vi) the identity of the health plan or health insur-
ance issuer, provider, or facility, with respect to the 
notification; 
‘‘(vii) the length of time in making each determina-
tion; 
‘‘(viii) the compensation paid to the certified IDR 
entity with respect to the settlement or determination; 
and 
‘‘(ix) any other information specified by the Sec-
retary. 
‘‘(C) IDR ENTITY REQUIREMENTS.—For 2022 and each 
subsequent year, an IDR entity, as a condition of certifi-
cation as an IDR entity, shall submit to the Secretary 
such information as the Secretary determines necessary 
to carry out the provisions of this subsection.
H. R. 133—1625 
‘‘(D) CLARIFICATION.—The Secretary shall ensure the 
public reporting under this paragraph does not contain 
information that would disclose privileged or confidential 
information of a group health plan or health insurance 
issuer offering group or individual health insurance cov-
erage or of a provider or facility. 
‘‘(8) ADMINISTRATIVE FEE.— 
‘‘(A) IN GENERAL.—Each party to a determination under 
paragraph (5) to which an entity is selected under para-
graph (3) in a year shall pay to the Secretary, at such 
time and in such manner as specified by the Secretary, 
a fee for participating in the IDR process with respect 
to such determination in an amount described in subpara-
graph (B) for such year. 
‘‘(B) AMOUNT OF FEE.—The amount described in this 
subparagraph for a year is an amount established by the 
Secretary in a manner such that the total amount of fees 
paid under this paragraph for such year is estimated to 
be equal to the amount of expenditures estimated to be 
made by the Secretary for such year in carrying out the 
IDR process. 
‘‘(9) WAIVER AUTHORITY.—The Secretary may modify any 
deadline or other timing requirement specified under this sub-
section (other than the establishment date for the IDR process 
under paragraph (2)(A) and other than under paragraph (6)) 
in cases of extenuating circumstances, as specified by the Sec-
retary, or to ensure that all claims that occur during a 90- 
day period described in paragraph (5)(E)(ii), but with respect 
to which a notification is not permitted by reason of such 
paragraph to be submitted under paragraph (1)(B) during such 
period, are eligible for the IDR process.’’. 
(b) ERISA.—Section 716 of the Employee Retirement Income 
Security Act of 1974, as added by section 102, is amended— 
(1) by redesignating subsection (c) as subsection (d); and 
(2) by inserting after subsection (b) the following new sub-
section: 
‘‘(c) DETERMINATION OF OUT-OF-NETWORK RATES TO BE PAID 
BY HEALTH PLANS; INDEPENDENT DISPUTE RESOLUTION PROCESS.— 
‘‘(1) DETERMINATION THROUGH OPEN NEGOTIATION.— 
‘‘(A) IN GENERAL.—With respect to an item or service 
furnished in a year by a nonparticipating provider or a 
nonparticipating facility, with respect to a group health 
plan or health insurance issuer offering group health insur-
ance coverage, in a State described in subsection 
(a)(3)(K)(ii) with respect to such plan or coverage and pro-
vider or facility, and for which a payment is required 
to be made by the plan or coverage pursuant to subsection 
(a)(1) or (b)(1), the provider or facility (as applicable) or 
plan or coverage may, during the 30-day period beginning 
on the day the provider or facility receives an initial pay-
ment or a notice of denial of payment from the plan or 
coverage regarding a claim for payment for such item or 
service, initiate open negotiations under this paragraph 
between such provider or facility and plan or coverage 
for purposes of determining, during the open negotiation 
period, an amount agreed on by such provider or facility, 
respectively, and such plan or coverage for payment
H. R. 133—1626 
(including any cost-sharing) for such item or service. For 
purposes of this subsection, the open negotiation period, 
with respect to an item or service, is the 30-day period 
beginning on the date of initiation of the negotiations with 
respect to such item or service. 
‘‘(B) ACCESSING
INDEPENDENT
DISPUTE
RESOLUTION 
PROCESS IN CASE OF FAILED NEGOTIATIONS.—In the case 
of open negotiations pursuant to subparagraph (A), with 
respect to an item or service, that do not result in a 
determination of an amount of payment for such item 
or service by the last day of the open negotiation period 
described in such subparagraph with respect to such item 
or service, the provider or facility (as applicable) or group 
health plan or health insurance issuer offering group health 
insurance coverage that was party to such negotiations 
may, during the 4-day period beginning on the day after 
such open negotiation period, initiate the independent dis-
pute resolution process under paragraph (2) with respect 
to such item or service. The independent dispute resolution 
process shall be initiated by a party pursuant to the pre-
vious sentence by submission to the other party and to 
the Secretary of a notification (containing such information 
as specified by the Secretary) and for purposes of this 
subsection, the date of initiation of such process shall be 
the date of such submission or such other date specified 
by the Secretary pursuant to regulations that is not later 
than the date of receipt of such notification by both the 
other party and the Secretary. 
‘‘(2) INDEPENDENT DISPUTE RESOLUTION PROCESS AVAILABLE 
IN CASE OF FAILED OPEN NEGOTIATIONS.— 
‘‘(A) ESTABLISHMENT.—Not later than 1 year after the 
date of the enactment of this subsection, the Secretary, 
jointly with the Secretary of Health and Human Services 
and the Secretary of the Treasury, shall establish by regula-
tion one independent dispute resolution process (referred 
to in this subsection as the ‘IDR process’) under which, 
in the case of an item or service with respect to which 
a provider or facility (as applicable) or group health plan 
or health insurance issuer offering group health insurance 
coverage submits a notification under paragraph (1)(B) (in 
this subsection referred to as a ‘qualified IDR item or 
service’), a certified IDR entity under paragraph (4) deter-
mines, subject to subparagraph (B) and in accordance with 
the succeeding provisions of this subsection, the amount 
of payment under the plan or coverage for such item or 
service furnished by such provider or facility. 
‘‘(B) AUTHORITY TO CONTINUE NEGOTIATIONS.—Under 
the independent dispute resolution process, in the case 
that the parties to a determination for a qualified IDR 
item or service agree on a payment amount for such item 
or service during such process but before the date on which 
the entity selected with respect to such determination 
under paragraph (4) makes such determination under para-
graph (5), such amount shall be treated for purposes of 
subsection (a)(3)(K)(ii) as the amount agreed to by such 
parties for such item or service. In the case of an agreement 
described in the previous sentence, the independent dispute
H. R. 133—1627 
resolution process shall provide for a method to determine 
how to allocate between the parties to such determination 
the payment of the compensation of the entity selected 
with respect to such determination. 
‘‘(C) CLARIFICATION.—A nonparticipating provider may 
not, with respect to an item or service furnished by such 
provider, submit a notification under paragraph (1)(B) if 
such provider is exempt from the requirement under sub-
section (a) of section 2799B–2 of the Public Health Service 
Act with respect to such item or service pursuant to sub-
section (b) of such section. 
‘‘(3) TREATMENT OF BATCHING OF ITEMS AND SERVICES.— 
‘‘(A) IN GENERAL.—Under the IDR process, the Sec-
retary shall specify criteria under which multiple qualified 
IDR dispute items and services are permitted to be consid-
ered jointly as part of a single determination by an entity 
for purposes of encouraging the efficiency (including mini-
mizing costs) of the IDR process. Such items and services 
may be so considered only if— 
‘‘(i) such items and services to be included in such 
determination are furnished by the same provider or 
facility; 
‘‘(ii) payment for such items and services is 
required to be made by the same group health plan 
or health insurance issuer; 
‘‘(iii) such items and services are related to the 
treatment of a similar condition; and 
‘‘(iv) such items and services were furnished during 
the 30 day period following the date on which the 
first item or service included with respect to such 
determination was furnished or an alternative period 
as determined by the Secretary, for use in limited 
situations, such as by the consent of the parties or 
in the case of low-volume items and services, to encour-
age procedural efficiency and minimize health plan 
and provider administrative costs. 
‘‘(B) TREATMENT OF BUNDLED PAYMENTS.—In carrying 
out subparagraph (A), the Secretary shall provide that, 
in the case of items and services which are included by 
a provider or facility as part of a bundled payment, such 
items and services included in such bundled payment may 
be part of a single determination under this subsection. 
‘‘(4) CERTIFICATION AND SELECTION OF IDR ENTITIES.— 
‘‘(A) IN GENERAL.—The Secretary, jointly with the Sec-
retary of Health and Human Services and Secretary of 
the Treasury, shall establish a process to certify (including 
to recertify) entities under this paragraph. Such process 
shall ensure that an entity so certified— 
‘‘(i) has (directly or through contracts or other 
arrangements) sufficient medical, legal, and other 
expertise and sufficient staffing to make determina-
tions described in paragraph (5) on a timely basis; 
‘‘(ii) is not— 
‘‘(I) a group health plan or health insurance 
issuer offering group health insurance coverage, 
provider, or facility;
H. R. 133—1628 
‘‘(II) an affiliate or a subsidiary of such a group 
health plan or health insurance issuer, provider, 
or facility; or 
‘‘(III) an affiliate or subsidiary of a professional 
or trade association of such group health plans 
or health insurance issuers or of providers or facili-
ties; 
‘‘(iii) carries out the responsibilities of such an 
entity in accordance with this subsection; 
‘‘(iv) meets appropriate indicators of fiscal integ-
rity; 
‘‘(v) maintains the confidentiality (in accordance 
with regulations promulgated by the Secretary) of 
individually identifiable health information obtained 
in the course of conducting such determinations; 
‘‘(vi) does not under the IDR process carry out 
any determination with respect to which the entity 
would not pursuant to subclause (I), (II), or (III) of 
subparagraph (F)(i) be eligible for selection; and 
‘‘(vii) meets such other requirements as determined 
appropriate by the Secretary. 
‘‘(B) PERIOD OF CERTIFICATION.—Subject to subpara-
graph (C), each certification (including a recertification) 
of an entity under the process described in subparagraph 
(A) shall be for a 5-year period. 
‘‘(C) REVOCATION.—A certification of an entity under 
this paragraph may be revoked under the process described 
in subparagraph (A) if the entity has a pattern or practice 
of noncompliance with any of the requirements described 
in such subparagraph. 
‘‘(D) PETITION
FOR
DENIAL
OR
WITHDRAWAL.—The 
process described in subparagraph (A) shall ensure that 
an individual, provider, facility, or group health plan or 
health insurance issuer offering group health insurance 
coverage may petition for a denial of a certification or 
a revocation of a certification with respect to an entity 
under this paragraph for failure of meeting a requirement 
of this subsection. 
‘‘(E) SUFFICIENT
NUMBER
OF
ENTITIES.—The process 
described in subparagraph (A) shall ensure that a sufficient 
number of entities are certified under this paragraph to 
ensure the timely and efficient provision of determinations 
described in paragraph (5). 
‘‘(F) SELECTION OF CERTIFIED IDR ENTITY.—The Sec-
retary shall, with respect to the determination of the 
amount of payment under this subsection of an item or 
service, provide for a method— 
‘‘(i) that allows for the group health plan or health 
insurance issuer offering group health insurance cov-
erage and the nonparticipating provider or the non-
participating 
emergency 
facility 
(as 
applicable) 
involved in a notification under paragraph (1)(B) to 
jointly select, not later than the last day of the 3- 
business day period following the date of the initiation 
of the process with respect to such item or service, 
for purposes of making such determination, an entity 
certified under this paragraph that—
H. R. 133—1629 
‘‘(I) is not a party to such determination or 
an employee or agent of such a party; 
‘‘(II) does not have a material familial, finan-
cial, or professional relationship with such a party; 
and 
‘‘(III) does not otherwise have a conflict of 
interest with such a party (as determined by the 
Secretary); and 
‘‘(ii) that requires, in the case such parties do 
not make such selection by such last day, the Secretary 
to, not later than 6 business days after such date 
of initiation— 
‘‘(I) select such an entity that satisfies sub-
clauses (I) through (III) of clause (i)); and 
‘‘(II) provide notification of such selection to 
the provider or facility (as applicable) and the plan 
or issuer (as applicable) party to such determina-
tion. 
An entity selected pursuant to the previous sentence to make a 
determination described in such sentence shall be referred to in 
this subsection as the ‘certified IDR entity’ with respect to such 
determination. 
‘‘(5) PAYMENT DETERMINATION.— 
‘‘(A) IN GENERAL.—Not later than 30 days after the 
date of selection of the certified IDR entity with respect 
to a determination for a qualified IDR item or service, 
the certified IDR entity shall— 
‘‘(i) taking into account the considerations specified 
in subparagraph (C), select one of the offers submitted 
under subparagraph (B) to be the amount of payment 
for such item or service determined under this sub-
section for purposes of subsection (a)(1) or (b)(1), as 
applicable; and 
‘‘(ii) notify the provider or facility and the group 
health plan or health insurance issuer offering group 
health insurance coverage party to such determination 
of the offer selected under clause (i). 
‘‘(B) SUBMISSION OF OFFERS.—Not later than 10 days 
after the date of selection of the certified IDR entity with 
respect to a determination for a qualified IDR item or 
service, the provider or facility and the group health plan 
or health insurance issuer offering group health insurance 
coverage party to such determination— 
‘‘(i) shall each submit to the certified IDR entity 
with respect to such determination— 
‘‘(I) an offer for a payment amount for such 
item or service furnished by such provider or 
facility; and 
‘‘(II) such information as requested by the cer-
tified IDR entity relating to such offer; and 
‘‘(ii) may each submit to the certified IDR entity 
with respect to such determination any information 
relating to such offer submitted by either party, 
including information relating to any circumstance 
described in subparagraph (C)(ii). 
‘‘(C) CONSIDERATIONS IN DETERMINATION.—
H. R. 133—1630 
‘‘(i) IN GENERAL.—In determining which offer is 
the payment to be applied pursuant to this paragraph, 
the certified IDR entity, with respect to the determina-
tion for a qualified IDR item or service shall consider— 
‘‘(I) the qualifying payment amounts (as 
defined in subsection (a)(3)(E)) for the applicable 
year for items or services that are comparable 
to the qualified IDR item or service and that are 
furnished in the same geographic region (as 
defined by the Secretary for purposes of such sub-
section) as such qualified IDR item or service; 
and 
‘‘(II) subject to subparagraph (D), information 
on any circumstance described in clause (ii), such 
information 
as 
requested 
in 
subparagraph 
(B)(i)(II), and any additional information provided 
in subparagraph (B)(ii). 
‘‘(ii) ADDITIONAL CIRCUMSTANCES.—For purposes of 
clause (i)(II), the circumstances described in this clause 
are, with respect to a qualified IDR item or service 
of a nonparticipating provider, nonparticipating emer-
gency facility, group health plan, or health insurance 
issuer of group health insurance coverage the following: 
‘‘(I) The level of training, experience, and 
quality and outcomes measurements of the pro-
vider or facility that furnished such item or service 
(such as those endorsed by the consensus-based 
entity authorized in section 1890 of the Social 
Security Act). 
‘‘(II) The market share held by the nonpartici-
pating provider or facility or that of the plan or 
issuer in the geographic region in which the item 
or service was provided. 
‘‘(III) The acuity of the individual receiving 
such item or service or the complexity of furnishing 
such item or service to such individual. 
‘‘(IV) The teaching status, case mix, and scope 
of services of the nonparticipating facility that fur-
nished such item or service. 
‘‘(V) Demonstrations of good faith efforts (or 
lack of good faith efforts) made by the nonpartici-
pating provider or nonparticipating facility or the 
plan or issuer to enter into network agreements 
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. 
‘‘(D) PROHIBITION ON CONSIDERATION OF CERTAIN FAC-
TORS.—In determining which offer is the payment to be 
applied with respect to qualified IDR items and services 
furnished by a provider or facility, the certified IDR entity 
with respect to a determination shall not consider usual 
and customary charges, the amount that would have been 
billed by such provider or facility with respect to such 
items and services had the provisions of section 2799B– 
1 of the Public Health Service Act or 2799B–2 of such 
Act (as applicable) not applied, or the payment or
H. R. 133—1631 
reimbursement rate for such items and services furnished 
by such provider or facility payable by a public payor, 
including under the Medicare program under title XVIII 
of the Social Security Act, under the Medicaid program 
under title XIX of such Act, under the Children’s Health 
Insurance Program under title XXI of such Act, under 
the TRICARE program under chapter 55 of title 10, United 
States Code, or under chapter 17 of title 38, United States 
Code. 
‘‘(E) EFFECTS OF DETERMINATION.— 
‘‘(i) IN GENERAL.—A determination of a certified 
IDR entity under subparagraph (A)— 
‘‘(I) shall be binding upon the parties involved, 
in the absence of a fraudulent claim or evidence 
of misrepresentation of facts presented to the IDR 
entity involved regarding such claim; and 
‘‘(II) shall not be 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. 
‘‘(ii) SUSPENSION
OF
CERTAIN
SUBSEQUENT
IDR 
REQUESTS.—In the case of a determination of a certified 
IDR entity under subparagraph (A), with respect to 
an initial notification submitted under paragraph (1)(B) 
with respect to qualified IDR items and services and 
the two parties involved with such notification, the 
party that submitted such notification may not submit 
during the 90-day period following such determination 
a subsequent notification under such paragraph 
involving the same other party to such notification 
with respect to such an item or service that was the 
subject of such initial notification. 
‘‘(iii) SUBSEQUENT SUBMISSION OF REQUESTS PER-
MITTED.—In the case of a notification that pursuant 
to clause (ii) is not permitted to be submitted under 
paragraph (1)(B) during a 90-day period specified in 
such clause, if the end of the open negotiation period 
specified in paragraph (1)(A), that but for this clause 
would otherwise apply with respect to such notification, 
occurs during such 90-day period, such paragraph 
(1)(B) shall be applied as if the reference in such para-
graph to the 4-day period beginning on the day after 
such open negotiation period were instead a reference 
to the 30-day period beginning on the day after the 
last day of such 90-day period. 
‘‘(iv) REPORTS.—The Secretary, jointly with the 
Secretary of Health and Human Services and the Sec-
retary of the Treasury, shall examine the impact of 
the application of clause (ii) and whether the applica-
tion of such clause delays payment determinations or 
impacts early, alternative resolution of claims (such 
as through open negotiations), and shall submit to 
Congress, not later than 2 years after the date of 
implementation of such clause an interim report (and 
not later than 4 years after such date of implementa-
tion, a final report) on whether any group health plans 
or health insurance issuers offering group or individual
H. R. 133—1632 
health insurance coverage or types of such plans or 
coverage have a pattern or practice of routine denial, 
low payment, or down-coding of claims, or otherwise 
abuse the 90-day period described in such clause, 
including recommendations on ways to discourage such 
a pattern or practice. 
‘‘(F) COSTS
OF
INDEPENDENT
DISPUTE
RESOLUTION 
PROCESS.—In the case of a notification under paragraph 
(1)(B) submitted by a nonparticipating provider, nonpartici-
pating emergency facility, group health plan, or health 
insurance issuer offering group health insurance coverage 
and submitted to a certified IDR entity— 
‘‘(i) if such entity makes a determination with 
respect to such notification under subparagraph (A), 
the party whose offer is not chosen under such subpara-
graph shall be responsible for paying all fees charged 
by such entity; and 
‘‘(ii) if the parties reach a settlement with respect 
to such notification prior to such a determination, each 
party shall pay half of all fees charged by such entity, 
unless the parties otherwise agree. 
‘‘(6) TIMING OF PAYMENT.—The total plan or coverage pay-
ment required pursuant to subsection (a)(1) or (b)(1), with 
respect to a qualified IDR item or service for which a determina-
tion is made under paragraph (5)(A) or with respect to an 
item or service for which a payment amount is determined 
under open negotiations under paragraph (1), shall be made 
directly to the nonparticipating provider or facility not later 
than 30 days after the date on which such determination is 
made. 
‘‘(7) PUBLICATION OF INFORMATION RELATING TO THE IDR 
PROCESS.— 
‘‘(A) PUBLICATION OF INFORMATION.—For each calendar 
quarter in 2022 and each calendar quarter in a subsequent 
year, the Secretary shall make available on the public 
website of the Department of Labor— 
‘‘(i) the number of notifications submitted under 
paragraph (1)(B) during such calendar quarter; 
‘‘(ii) the size of the provider practices and the 
size of the facilities submitting notifications under 
paragraph (1)(B) during such calendar quarter; 
‘‘(iii) the number of such notifications with respect 
to which a determination was made under paragraph 
(5)(A); 
‘‘(iv) the information described in subparagraph 
(B) with respect to each notification with respect to 
which such a determination was so made; 
‘‘(v) the number of times the payment amount 
determined (or agreed to) under this subsection exceeds 
the qualifying payment amount, specified by items and 
services; 
‘‘(vi) the amount of expenditures made by the Sec-
retary during such calendar quarter to carry out the 
IDR process; 
‘‘(vii) the total amount of fees paid under para-
graph (8) during such calendar quarter; and
H. R. 133—1633 
‘‘(viii) the total amount of compensation paid to 
certified IDR entities under paragraph (5)(F) during 
such calendar quarter. 
‘‘(B) INFORMATION.—For purposes of subparagraph (A), 
the information described in this subparagraph is, with 
respect to a notification under paragraph (1)(B) by a non-
participating provider, nonparticipating emergency facility, 
group health plan, or health insurance issuer offering group 
health insurance coverage— 
‘‘(i) a description of each item and service included 
with respect to such notification; 
‘‘(ii) the geography in which the items and services 
with respect to such notification were provided; 
‘‘(iii) the amount of the offer submitted under para-
graph (5)(B) by the group health plan or health insur-
ance issuer (as applicable) and by the nonparticipating 
provider or nonparticipating emergency facility (as 
applicable) expressed as a percentage of the qualifying 
payment amount; 
‘‘(iv) whether the offer selected by the certified 
IDR entity under paragraph (5) to be the payment 
applied was the offer submitted by such plan or issuer 
(as applicable) or by such provider or facility (as 
applicable) and the amount of such offer so selected 
expressed as a percentage of the qualifying payment 
amount; 
‘‘(v) the category and practice specialty of each 
such provider or facility involved in furnishing such 
items and services; 
‘‘(vi) the identity of the health plan or health insur-
ance issuer, provider, or facility, with respect to the 
notification; 
‘‘(vii) the length of time in making each determina-
tion; 
‘‘(viii) the compensation paid to the certified IDR 
entity with respect to the settlement or determination; 
and 
‘‘(ix) any other information specified by the Sec-
retary. 
‘‘(C) IDR ENTITY REQUIREMENTS.—For 2022 and each 
subsequent year, an IDR entity, as a condition of certifi-
cation as an IDR entity, shall submit to the Secretary 
such information as the Secretary determines necessary 
to carry out the provisions of this subsection. 
‘‘(D) CLARIFICATION.—The Secretary shall ensure the 
public reporting under this paragraph does not contain 
information that would disclose privileged or confidential 
information of a group health plan or health insurance 
issuer offering group or individual health insurance cov-
erage or of a provider or facility. 
‘‘(8) ADMINISTRATIVE FEE.— 
‘‘(A) IN GENERAL.—Each party to a determination under 
paragraph (5) to which an entity is selected under para-
graph (3) in a year shall pay to the Secretary, at such 
time and in such manner as specified by the Secretary, 
a fee for participating in the IDR process with respect
H. R. 133—1634 
to such determination in an amount described in subpara-
graph (B) for such year. 
‘‘(B) AMOUNT OF FEE.—The amount described in this 
subparagraph for a year is an amount established by the 
Secretary in a manner such that the total amount of fees 
paid under this paragraph for such year is estimated to 
be equal to the amount of expenditures estimated to be 
made by the Secretary for such year in carrying out the 
IDR process. 
‘‘(9) WAIVER AUTHORITY.—The Secretary may modify any 
deadline or other timing requirement specified under this sub-
section (other than the establishment date for the IDR process 
under paragraph (2)(A) and other than under paragraph (6)) 
in cases of extenuating circumstances, as specified by the Sec-
retary, or to ensure that all claims that occur during a 90- 
day period described in paragraph (5)(E)(ii), but with respect 
to which a notification is not permitted by reason of such 
paragraph to be submitted under paragraph (1)(B) during such 
period, are eligible for the IDR process.’’. 
(c) IRC.—Section 9816 of the Internal Revenue Code of 1986, 
as added by section 102, is amended— 
(1) by redesignating subsection (c) as subsection (d); and 
(2) by inserting after subsection (b) the following new sub-
section: 
‘‘(c) DETERMINATION OF OUT-OF-NETWORK RATES TO BE PAID 
BY HEALTH PLANS; INDEPENDENT DISPUTE RESOLUTION PROCESS.— 
‘‘(1) DETERMINATION THROUGH OPEN NEGOTIATION.— 
‘‘(A) IN GENERAL.—With respect to an item or service 
furnished in a year by a nonparticipating provider or a 
nonparticipating facility, with respect to a group health 
plan, in a State described in subsection (a)(3)(K)(ii) with 
respect to such plan and provider or facility, and for which 
a payment is required to be made by the plan pursuant 
to subsection (a)(1) or (b)(1), the provider or facility (as 
applicable) or plan may, during the 30-day period beginning 
on the day the provider or facility receives an initial pay-
ment or a notice of denial of payment from the plan 
regarding a claim for payment for such item or service, 
initiate open negotiations under this paragraph between 
such provider or facility and plan for purposes of deter-
mining, during the open negotiation period, an amount 
agreed on by such provider or facility, respectively, and 
such plan for payment (including any cost-sharing) for such 
item or service. For purposes of this subsection, the open 
negotiation period, with respect to an item or service, is 
the 30-day period beginning on the date of initiation of 
the negotiations with respect to such item or service. 
‘‘(B) ACCESSING
INDEPENDENT
DISPUTE
RESOLUTION 
PROCESS IN CASE OF FAILED NEGOTIATIONS.—In the case 
of open negotiations pursuant to subparagraph (A), with 
respect to an item or service, that do not result in a 
determination of an amount of payment for such item 
or service by the last day of the open negotiation period 
described in such subparagraph with respect to such item 
or service, the provider or facility (as applicable) or group 
health plan that was party to such negotiations may, during 
the 4-day period beginning on the day after such open
H. R. 133—1635 
negotiation period, initiate the independent dispute resolu-
tion process under paragraph (2) with respect to such item 
or service. The independent dispute resolution process shall 
be initiated by a party pursuant to the previous sentence 
by submission to the other party and to the Secretary 
of a notification (containing such information as specified 
by the Secretary) and for purposes of this subsection, the 
date of initiation of such process shall be the date of such 
submission or such other date specified by the Secretary 
pursuant to regulations that is not later than the date 
of receipt of such notification by both the other party and 
the Secretary. 
‘‘(2) INDEPENDENT DISPUTE RESOLUTION PROCESS AVAILABLE 
IN CASE OF FAILED OPEN NEGOTIATIONS.— 
‘‘(A) ESTABLISHMENT.—Not later than 1 year after the 
date of the enactment of this subsection, the Secretary, 
jointly with the Secretary of Health and Human Services 
and the Secretary of Labor, shall establish by regulation 
one independent dispute resolution process (referred to in 
this subsection as the ‘IDR process’) under which, in the 
case of an item or service with respect to which a provider 
or facility (as applicable) or group health plan submits 
a notification under paragraph (1)(B) (in this subsection 
referred to as a ‘qualified IDR item or service’), a certified 
IDR entity under paragraph (4) determines, subject to 
subparagraph (B) and in accordance with the succeeding 
provisions of this subsection, the amount of payment under 
the plan for such item or service furnished by such provider 
or facility. 
‘‘(B) AUTHORITY TO CONTINUE NEGOTIATIONS.—Under 
the independent dispute resolution process, in the case 
that the parties to a determination for a qualified IDR 
item or service agree on a payment amount for such item 
or service during such process but before the date on which 
the entity selected with respect to such determination 
under paragraph (4) makes such determination under para-
graph (5), such amount shall be treated for purposes of 
subsection (a)(3)(K)(ii) as the amount agreed to by such 
parties for such item or service. In the case of an agreement 
described in the previous sentence, the independent dispute 
resolution process shall provide for a method to determine 
how to allocate between the parties to such determination 
the payment of the compensation of the entity selected 
with respect to such determination. 
‘‘(C) CLARIFICATION.—A nonparticipating provider may 
not, with respect to an item or service furnished by such 
provider, submit a notification under paragraph (1)(B) if 
such provider is exempt from the requirement under sub-
section (a) of section 2799B–2 of the Public Health Service 
Act with respect to such item or service pursuant to sub-
section (b) of such section. 
‘‘(3) TREATMENT OF BATCHING OF ITEMS AND SERVICES.— 
‘‘(A) IN GENERAL.—Under the IDR process, the Sec-
retary shall specify criteria under which multiple qualified 
IDR dispute items and services are permitted to be consid-
ered jointly as part of a single determination by an entity
H. R. 133—1636 
for purposes of encouraging the efficiency (including mini-
mizing costs) of the IDR process. Such items and services 
may be so considered only if— 
‘‘(i) such items and services to be included in such 
determination are furnished by the same provider or 
facility; 
‘‘(ii) payment for such items and services is 
required to be made by the same group health plan 
or health insurance issuer; 
‘‘(iii) such items and services are related to the 
treatment of a similar condition; and 
‘‘(iv) such items and services were furnished during 
the 30 day period following the date on which the 
first item or service included with respect to such 
determination was furnished or an alternative period 
as determined by the Secretary, for use in limited 
situations, such as by the consent of the parties or 
in the case of low-volume items and services, to encour-
age procedural efficiency and minimize health plan 
and provider administrative costs. 
‘‘(B) TREATMENT OF BUNDLED PAYMENTS.—In carrying 
out subparagraph (A), the Secretary shall provide that, 
in the case of items and services which are included by 
a provider or facility as part of a bundled payment, such 
items and services included in such bundled payment may 
be part of a single determination under this subsection. 
‘‘(4) CERTIFICATION AND SELECTION OF IDR ENTITIES.— 
‘‘(A) IN GENERAL.—The Secretary, jointly with the Sec-
retary of Health and Human Services and the Secretary 
of Labor, shall establish a process to certify (including 
to recertify) entities under this paragraph. Such process 
shall ensure that an entity so certified— 
‘‘(i) has (directly or through contracts or other 
arrangements) sufficient medical, legal, and other 
expertise and sufficient staffing to make determina-
tions described in paragraph (5) on a timely basis; 
‘‘(ii) is not— 
‘‘(I) a group health plan, provider, or facility; 
‘‘(II) an affiliate or a subsidiary of such a group 
health plan, provider, or facility; or 
‘‘(III) an affiliate or subsidiary of a professional 
or trade association of such group health plans 
or of providers or facilities; 
‘‘(iii) carries out the responsibilities of such an 
entity in accordance with this subsection; 
‘‘(iv) meets appropriate indicators of fiscal integ-
rity; 
‘‘(v) maintains the confidentiality (in accordance 
with regulations promulgated by the Secretary) of 
individually identifiable health information obtained 
in the course of conducting such determinations; 
‘‘(vi) does not under the IDR process carry out 
any determination with respect to which the entity 
would not pursuant to subclause (I), (II), or (III) of 
subparagraph (F)(i) be eligible for selection; and 
‘‘(vii) meets such other requirements as determined 
appropriate by the Secretary.
H. R. 133—1637 
‘‘(B) PERIOD OF CERTIFICATION.—Subject to subpara-
graph (C), each certification (including a recertification) 
of an entity under the process described in subparagraph 
(A) shall be for a 5-year period. 
‘‘(C) REVOCATION.—A certification of an entity under 
this paragraph may be revoked under the process described 
in subparagraph (A) if the entity has a pattern or practice 
of noncompliance with any of the requirements described 
in such subparagraph. 
‘‘(D) PETITION
FOR
DENIAL
OR
WITHDRAWAL.—The 
process described in subparagraph (A) shall ensure that 
an individual, provider, facility, or group health plan may 
petition for a denial of a certification or a revocation of 
a certification with respect to an entity under this para-
graph for failure of meeting a requirement of this sub-
section. 
‘‘(E) SUFFICIENT
NUMBER
OF
ENTITIES.—The process 
described in subparagraph (A) shall ensure that a sufficient 
number of entities are certified under this paragraph to 
ensure the timely and efficient provision of determinations 
described in paragraph (5). 
‘‘(F) SELECTION OF CERTIFIED IDR ENTITY.—The Sec-
retary shall, with respect to the determination of the 
amount of payment under this subsection of an item or 
service, provide for a method— 
‘‘(i) that allows for the group health plan and the 
nonparticipating provider or the nonparticipating 
emergency facility (as applicable) involved in a notifica-
tion under paragraph (1)(B) to jointly select, not later 
than the last day of the 3-business day period following 
the date of the initiation of the process with respect 
to such item or service, for purposes of making such 
determination, an entity certified under this paragraph 
that— 
‘‘(I) is not a party to such determination or 
an employee or agent of such a party; 
‘‘(II) does not have a material familial, finan-
cial, or professional relationship with such a party; 
and 
‘‘(III) does not otherwise have a conflict of 
interest with such a party (as determined by the 
Secretary); and 
‘‘(ii) that requires, in the case such parties do 
not make such selection by such last day, the Secretary 
to, not later than 6 business days after such date 
of initiation— 
‘‘(I) select such an entity that satisfies sub-
clauses (I) through (III) of clause (i)); and 
‘‘(II) provide notification of such selection to 
the provider or facility (as applicable) and the plan 
or issuer (as applicable) party to such determina-
tion. 
An entity selected pursuant to the previous sentence to make a 
determination described in such sentence shall be referred to in 
this subsection as the ‘certified IDR entity’ with respect to such 
determination. 
‘‘(5) PAYMENT DETERMINATION.—
H. R. 133—1638 
‘‘(A) IN GENERAL.—Not later than 30 days after the 
date of selection of the certified IDR entity with respect 
to a determination for a qualified IDR item or service, 
the certified IDR entity shall— 
‘‘(i) taking into account the considerations specified 
in subparagraph (C), select one of the offers submitted 
under subparagraph (B) to be the amount of payment 
for such item or service determined under this sub-
section for purposes of subsection (a)(1) or (b)(1), as 
applicable; and 
‘‘(ii) notify the provider or facility and the group 
health plan party to such determination of the offer 
selected under clause (i). 
‘‘(B) SUBMISSION OF OFFERS.—Not later than 10 days 
after the date of selection of the certifed IDR entity with 
respect to a determination for a qualified IDR item or 
service, the provider or facility and the group health plan 
party to such determination— 
‘‘(i) shall each submit to the certified IDR entity 
with respect to such determination— 
‘‘(I) an offer for a payment amount for such 
item or service furnished by such provider or 
facility; and 
‘‘(II) such information as requested by the cer-
tified IDR entity relating to such offer; and 
‘‘(ii) may each submit to the certified IDR entity 
with respect to such determination any information 
relating to such offer submitted by either party, 
including information relating to any circumstance 
described in subparagraph (C)(ii). 
‘‘(C) CONSIDERATIONS IN DETERMINATION.— 
‘‘(i) IN GENERAL.—In determining which offer is 
the payment to be applied pursuant to this paragraph, 
the certified IDR entity, with respect to the determina-
tion for a qualified IDR item or service shall consider— 
‘‘(I) the qualifying payment amounts (as 
defined in subsection (a)(3)(E)) for the applicable 
year for items or services that are comparable 
to the qualified IDR item or service and that are 
furnished in the same geographic region (as 
defined by the Secretary for purposes of such sub-
section) as such qualified IDR item or service; 
and 
‘‘(II) subject to subparagraph (D), information 
on any circumstance described in clause (ii), such 
information 
as 
requested 
in 
subparagraph 
(B)(i)(II), and any additional information provided 
in subparagraph (B)(ii). 
‘‘(ii) ADDITIONAL CIRCUMSTANCES.—For purposes of 
clause (i)(II), the circumstances described in this clause 
are, with respect to a qualified IDR item or service 
of a nonparticipating provider, nonparticipating emer-
gency facility, or group health plan, the following: 
‘‘(I) The level of training, experience, and 
quality and outcomes measurements of the pro-
vider or facility that furnished such item or service 
(such as those endorsed by the consensus-based
H. R. 133—1639 
entity authorized in section 1890 of the Social 
Security Act). 
‘‘(II) The market share held by the nonpartici-
pating provider or facility or that of the plan or 
issuer in the geographic region in which the item 
or service was provided. 
‘‘(III) The acuity of the individual receiving 
such item or service or the complexity of furnishing 
such item or service to such individual. 
‘‘(IV) The teaching status, case mix, and scope 
of services of the nonparticipating facility that fur-
nished such item or service. 
‘‘(V) Demonstrations of good faith efforts (or 
lack of good faith efforts) made by the nonpartici-
pating provider or nonparticipating facility or the 
plan or issuer to enter into network agreements 
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. 
‘‘(D) PROHIBITION ON CONSIDERATION OF CERTAIN FAC-
TORS.—In determining which offer is the payment to be 
applied with respect to qualified IDR items and services 
furnished by a provider or facility, the certified IDR entity 
with respect to a determination shall not consider usual 
and customary charges, the amount that would have been 
billed by such provider or facility with respect to such 
items and services had the provisions of section 2799B– 
1 of the Public Health Service Act or 2799B–2 of such 
Act (as applicable) not applied, or the payment or 
reimbursement rate for such items and services furnished 
by such provider or facility payable by a public payor, 
including under the Medicare program under title XVIII 
of the Social Security Act, under the Medicaid program 
under title XIX of such Act, under the Children’s Health 
Insurance Program under title XXI of such Act, under 
the TRICARE program under chapter 55 of title 10, United 
States Code, or under chapter 17 of title 38, United States 
Code. 
‘‘(E) EFFECTS OF DETERMINATION.— 
‘‘(i) IN GENERAL.—A determination of a certified 
IDR entity under subparagraph (A)— 
‘‘(I) shall be binding upon the parties involved, 
in the absence of a fraudulent claim or evidence 
of misrepresentation of facts presented to the IDR 
entity involved regarding such claim; and 
‘‘(II) shall not be 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. 
‘‘(ii) SUSPENSION
OF
CERTAIN
SUBSEQUENT
IDR 
REQUESTS.—In the case of a determination of a certified 
IDR entity under subparagraph (A), with respect to 
an initial notification submitted under paragraph (1)(B) 
with respect to qualified IDR items and services and 
the two parties involved with such notification, the 
party that submitted such notification may not submit
H. R. 133—1640 
during the 90-day period following such determination 
a subsequent notification under such paragraph 
involving the same other party to such notification 
with respect to such an item or service that was the 
subject of such initial notification. 
‘‘(iii) SUBSEQUENT SUBMISSION OF REQUESTS PER-
MITTED.—In the case of a notification that pursuant 
to clause (ii) is not permitted to be submitted under 
paragraph (1)(B) during a 90-day period specified in 
such clause, if the end of the open negotiation period 
specified in paragraph (1)(A), that but for this clause 
would otherwise apply with respect to such notification, 
occurs during such 90-day period, such paragraph 
(1)(B) shall be applied as if the reference in such para-
graph to the 4-day period beginning on the day after 
such open negotiation period were instead a reference 
to the 30-day period beginning on the day after the 
last day of such 90-day period. 
‘‘(iv) REPORTS.—The Secretary, jointly with the 
Secretary of Labor and the Secretary of the Health 
and Human Services, shall examine the impact of the 
application of clause (ii) and whether the application 
of such clause delays payment determinations or 
impacts early, alternative resolution of claims (such 
as through open negotiations), and shall submit to 
Congress, not later than 2 years after the date of 
implementation of such clause an interim report (and 
not later than 4 years after such date of implementa-
tion, a final report) on whether any group health plans 
or health insurance issuers offering group or individual 
health insurance coverage or types of such plans or 
coverage have a pattern or practice of routine denial, 
low payment, or down-coding of claims, or otherwise 
abuse the 90-day period described in such clause, 
including recommendations on ways to discourage such 
a pattern or practice. 
‘‘(F) COSTS
OF
INDEPENDENT
DISPUTE
RESOLUTION 
PROCESS.—In the case of a notification under paragraph 
(1)(B) submitted by a nonparticipating provider, nonpartici-
pating emergency facility, or group health plan and sub-
mitted to a certified IDR entity— 
‘‘(i) if such entity makes a determination with 
respect to such notification under subparagraph (A), 
the party whose offer is not chosen under such subpara-
graph shall be responsible for paying all fees charged 
by such entity; and 
‘‘(ii) if the parties reach a settlement with respect 
to such notification prior to such a determination, each 
party shall pay half of all fees charged by such entity, 
unless the parties otherwise agree. 
‘‘(6) TIMING OF PAYMENT.—The total plan payment required 
pursuant to subsection (a)(1) or (b)(1), with respect to a qualified 
IDR item or service for which a determination is made under 
paragraph (5)(A) or with respect to an item or service for
H. R. 133—1641 
which a payment amount is determined under open negotia-
tions under paragraph (1), shall be made directly to the non-
participating provider or facility not later than 30 days after 
the date on which such determination is made. 
‘‘(7) PUBLICATION OF INFORMATION RELATING TO THE IDR 
PROCESS.— 
‘‘(A) PUBLICATION OF INFORMATION.—For each calendar 
quarter in 2022 and each calendar quarter in a subsequent 
year, the Secretary shall make available on the public 
website of the Department of the Treasury— 
‘‘(i) the number of notifications submitted under 
paragraph (1)(B) during such calendar quarter; 
‘‘(ii) the size of the provider practices and the 
size of the facilities submitting notifications under 
paragraph (1)(B) during such calendar quarter; 
‘‘(iii) the number of such notifications with respect 
to which a determination was made under paragraph 
(5)(A); 
‘‘(iv) the information described in subparagraph 
(B) with respect to each notification with respect to 
which such a determination was so made; 
‘‘(v) the number of times the payment amount 
determined (or agreed to) under this subsection exceeds 
the qualifying payment amount, specified by items and 
services; 
‘‘(vi) the amount of expenditures made by the Sec-
retary during such calendar quarter to carry out the 
IDR process; 
‘‘(vii) the total amount of fees paid under para-
graph (8) during such calendar quarter; and 
‘‘(viii) the total amount of compensation paid to 
certified IDR entities under paragraph (5)(F) during 
such calendar quarter. 
‘‘(B) INFORMATION.—For purposes of subparagraph (A), 
the information described in this subparagraph is, with 
respect to a notification under paragraph (1)(B) by a non-
participating provider, nonparticipating emergency facility, 
or group health plan— 
‘‘(i) a description of each item and service included 
with respect to such notification; 
‘‘(ii) the geography in which the items and services 
with respect to such notification were provided; 
‘‘(iii) the amount of the offer submitted under para-
graph (5)(B) by the group health plan and by the 
nonparticipating provider or nonparticipating emer-
gency facility (as applicable) expressed as a percentage 
of the qualifying payment amount; 
‘‘(iv) whether the offer selected by the certified 
IDR entity under paragraph (5) to be the payment 
applied was the offer submitted by such plan or by 
such provider or facility (as applicable) and the amount 
of such offer so selected expressed as a percentage 
of the qualifying payment amount; 
‘‘(v) the category and practice specialty of each 
such provider or facility involved in furnishing such 
items and services;
H. R. 133—1642 
‘‘(vi) the identity of the group health plan, provider, 
or facility, with respect to the notification; 
‘‘(vii) the length of time in making each determina-
tion; 
‘‘(viii) the compensation paid to the certified IDR 
entity with respect to the settlement or determination; 
and 
‘‘(ix) any other information specified by the Sec-
retary. 
‘‘(C) IDR ENTITY REQUIREMENTS.—For 2022 and each 
subsequent year, an IDR entity, as a condition of certifi-
cation as an IDR entity, shall submit to the Secretary 
such information as the Secretary determines necessary 
to carry out the provisions of this subsection. 
‘‘(D) CLARIFICATION.—The Secretary shall ensure the 
public reporting under this paragraph does not contain 
information that would disclose privileged or confidential 
information of a group health plan or health insurance 
issuer offering group or individual health insurance cov-
erage or of a provider or facility. 
‘‘(8) ADMINISTRATIVE FEE.— 
‘‘(A) IN GENERAL.—Each party to a determination under 
paragraph (5) to which an entity is selected under para-
graph (3) in a year shall pay to the Secretary, at such 
time and in such manner as specified by the Secretary, 
a fee for participating in the IDR process with respect 
to such determination in an amount described in subpara-
graph (B) for such year. 
‘‘(B) AMOUNT OF FEE.—The amount described in this 
subparagraph for a year is an amount established by the 
Secretary in a manner such that the total amount of fees 
paid under this paragraph for such year is estimated to 
be equal to the amount of expenditures estimated to be 
made by the Secretary for such year in carrying out the 
IDR process. 
‘‘(9) WAIVER AUTHORITY.—The Secretary may modify any 
deadline or other timing requirement specified under this sub-
section (other than the establishment date for the IDR process 
under paragraph (2)(A) and other than under paragraph (6)) 
in cases of extenuating circumstances, as specified by the Sec-
retary, or to ensure that all claims that occur during a 90- 
day period described in paragraph (5)(E)(ii), but with respect 
to which a notification is not permitted by reason of such 
paragraph to be submitted under paragraph (1)(B) during such 
period, are eligible for the IDR process.’’. 
SEC. 104. HEALTH CARE PROVIDER REQUIREMENTS REGARDING SUR-
PRISE MEDICAL BILLING. 
(a) IN GENERAL.—Title XXVII of the Public Health Service 
Act (42 U.S.C. 300gg et seq.) is amended by inserting after part 
D, as added by section 102, the following:
H. R. 133—1643 
‘‘PART E—HEALTH CARE PROVIDER 
REQUIREMENTS 
‘‘SEC. 2799B–1. BALANCE BILLING IN CASES OF EMERGENCY SERVICES. 
‘‘(a) IN GENERAL.—In the case of a participant, beneficiary, 
or enrollee with benefits under a group health plan or group or 
individual health insurance coverage offered by a health insurance 
issuer and who is furnished during a plan year beginning on or 
after January 1, 2022, emergency services (for which benefits are 
provided under the plan or coverage) with respect to an emergency 
medical condition with respect to a visit at an emergency depart-
ment of a hospital or an independent freestanding emergency 
department— 
‘‘(1) in the case that the hospital or independent free-
standing emergency department is a nonparticipating emer-
gency facility, the emergency department of a hospital or inde-
pendent freestanding emergency department shall not bill, and 
shall not hold liable, the participant, beneficiary, or enrollee 
for a payment amount for such emergency services so furnished 
that is more than the cost-sharing requirement for such services 
(as determined in accordance with clauses (ii) and (iii) of section 
2799A–1(a)(1)(C), of section 9816(a)(1)(C) of the Internal Rev-
enue Code of 1986, and of section 716(a)(1)(C) of the Employee 
Retirement Income Security Act of 1974, as applicable); and 
‘‘(2) in the case that such services are furnished by a 
nonparticipating provider, the health care provider shall not 
bill, and shall not hold liable, such participant, beneficiary, 
or enrollee for a payment amount for an emergency service 
furnished to such individual by such provider with respect 
to such emergency medical condition and visit for which the 
individual receives emergency services at the hospital or emer-
gency department that is more than the cost-sharing require-
ment for such services furnished by the provider (as determined 
in accordance with clauses (ii) and (iii) of section 2799A– 
1(a)(1)(C), of section 9816(a)(1)(C) of the Internal Revenue Code 
of 1986, and of section 716(a)(1)(C) of the Employee Retirement 
Income Security Act of 1974, as applicable). 
‘‘(b) DEFINITION.—In this section, the term ‘visit’ shall have 
such meaning as applied to such term for purposes of section 
2799A–1(b). 
‘‘SEC. 2799B–2. BALANCE BILLING IN CASES OF NON-EMERGENCY SERV-
ICES PERFORMED BY NONPARTICIPATING PROVIDERS 
AT CERTAIN PARTICIPATING FACILITIES. 
‘‘(a) IN GENERAL.—Subject to subsection (b), in the case of 
a participant, beneficiary, or enrollee with benefits under a group 
health plan or group or individual health insurance coverage offered 
by a health insurance issuer and who is furnished during a plan 
year beginning on or after January 1, 2022, items or services 
(other than emergency services to which section 2799B–1 applies) 
for which benefits are provided under the plan or coverage at 
a participating health care facility by a nonparticipating provider, 
such provider shall not bill, and shall not hold liable, such partici-
pant, beneficiary, or enrollee for a payment amount for such an 
item or service furnished by such provider with respect to a visit 
at such facility that is more than the cost-sharing requirement
H. R. 133—1644 
for such item or service (as determined in accordance with subpara-
graphs (A) and (B) of section 2799A–1(b)(1) of section 9816(b)(1) 
of the Internal Revenue Code of 1986, and of section 716(b)(1) 
of the Employee Retirement Income Security Act of 1974, as 
applicable). 
‘‘(b) EXCEPTION.— 
‘‘(1) IN
GENERAL.—Subsection (a) shall not apply with 
respect to items or services (other than ancillary services 
described in paragraph (2)) furnished by a nonparticipating 
provider to a participant, beneficiary, or enrollee of a group 
health plan or group or individual health insurance coverage 
offered by a health insurance issuer, if the provider satisfies 
the notice and consent criteria of subsection (d). 
‘‘(2) ANCILLARY
SERVICES
DESCRIBED.—For purposes of 
paragraph (1), ancillary services described in this paragraph 
are, with respect to a participating health care facility— 
‘‘(A) subject to paragraph (3), items and services related 
to emergency medicine, anesthesiology, pathology, radi-
ology, and neonatology, whether or not provided by a physi-
cian or non-physician practitioner, and items and services 
provided 
by 
assistant 
surgeons, 
hospitalists, 
and 
intensivists; 
‘‘(B) subject to paragraph (3), diagnostic services 
(including radiology and laboratory services); 
‘‘(C) items and services provided by such other specialty 
practitioners, as the Secretary specifies through rule-
making; and 
‘‘(D) items and services provided by a nonparticipating 
provider if there is no participating provider who can fur-
nish such item or service at such facility. 
‘‘(3) EXCEPTION.—The Secretary may, through rulemaking, 
establish a list (and update such list periodically) of advanced 
diagnostic laboratory tests, which shall not be included as an 
ancillary service described in paragraph (2) and with respect 
to which subsection (a) would apply. 
‘‘(c) CLARIFICATION.—In the case of a nonparticipating provider 
that satisfies the notice and consent criteria of subsection (d) with 
respect to an item or service (referred to in this subsection as 
a ‘covered item or service’), such notice and consent criteria may 
not be construed as applying with respect to any item or service 
that is furnished as a result of unforeseen, urgent medical needs 
that arise at the time such covered item or service is furnished. 
For purposes of the previous sentence, a covered item or service 
shall not include an ancillary service described in subsection (b)(2). 
‘‘(d) NOTICE AND CONSENT TO BE TREATED BY A NONPARTICI-
PATING PROVIDER OR NONPARTICIPATING FACILITY.— 
‘‘(1) IN
GENERAL.—A nonparticipating provider or non-
participating facility satisfies the notice and consent criteria 
of this subsection, with respect to items or services furnished 
by the provider or facility to a participant, beneficiary, or 
enrollee of a group health plan or group or individual health 
insurance coverage offered by a health insurance issuer, if 
the provider (or, if applicable, the participating health care 
facility on behalf of such provider) or nonparticipating facility— 
‘‘(A) in the case that the participant, beneficiary, or 
enrollee makes an appointment to be furnished such items 
or services at least 72 hours prior to the date on which
H. R. 133—1645 
the individual is to be furnished such items or services, 
provides to the participant, beneficiary, or enrollee (or to 
an authorized representative of the participant, beneficiary, 
or enrollee) not later than 72 hours prior to the date 
on which the individual is furnished such items or services 
(or, in the case that the participant, beneficiary, or enrollee 
makes such an appointment within 72 hours of when such 
items or services are to be furnished, provides to the partici-
pant, beneficiary, or enrollee (or to an authorized represent-
ative of the participant, beneficiary, or enrollee) on such 
date the appointment is made), a written notice in paper 
or electronic form, as selected by the participant, bene-
ficiary, or enrollee, (and including electronic notification, 
as practicable) specified by the Secretary, not later than 
July 1, 2021, through guidance (which shall be updated 
as determined necessary by the Secretary) that— 
‘‘(i) contains the information required under para-
graph (2); 
‘‘(ii) clearly states that consent to receive such 
items and services from such nonparticipating provider 
or nonparticipating facility is optional and that the 
participant, beneficiary, or enrollee may instead seek 
care from a participating provider or at a participating 
facility, with respect to such plan or coverage, as 
applicable, in which case the cost-sharing responsibility 
of the participant, beneficiary, or enrollee would not 
exceed such responsibility that would apply with 
respect to such an item or service that is furnished 
by a participating provider or participating facility, 
as applicable with respect to such plan; and 
‘‘(iii) is available in the 15 most common languages 
in the geographic region of the applicable facility; 
‘‘(B) obtains from the participant, beneficiary, or 
enrollee (or from such an authorized representative) the 
consent described in paragraph (3) to be treated by a non-
participating provider or nonparticipating facility; and 
‘‘(C) provides a signed copy of such consent to the 
participant, beneficiary, or enrollee through mail or email 
(as selected by the participant, beneficiary, or enrollee). 
‘‘(2) INFORMATION REQUIRED UNDER WRITTEN NOTICE.—For 
purposes of paragraph (1)(A)(i), the information described in 
this paragraph, with respect to a nonparticipating provider 
or nonparticipating facility and a participant, beneficiary, or 
enrollee of a group health plan or group or individual health 
insurance coverage offered by a health insurance issuer, is 
each of the following: 
‘‘(A) Notification, as applicable, that the health care 
provider is a nonparticipating provider with respect to the 
health plan or the health care facility is a nonparticipating 
facility with respect to the health plan. 
‘‘(B) Notification of the good faith estimated amount 
that such provider or facility may charge the participant, 
beneficiary, or enrollee for such items and services involved, 
including a notification that the provision of such estimate 
or consent to be treated under paragraph (3) does not 
constitute a contract with respect to the charges estimated 
for such items and services.
H. R. 133—1646 
‘‘(C) In the case of a participating facility and a non-
participating provider, a list of any participating providers 
at the facility who are able to furnish such items and 
services involved and notification that the participant, 
beneficiary, or enrollee may be referred, at their option, 
to such a participating provider. 
‘‘(D) Information about whether prior authorization or 
other care management limitations may be required in 
advance of receiving such items or services at the facility. 
‘‘(3) CONSENT DESCRIBED TO BE TREATED BY A NONPARTICI-
PATING
PROVIDER
OR
NONPARTICIPATING
FACILITY.—For pur-
poses of paragraph (1)(B), the consent described in this para-
graph, with respect to a participant, beneficiary, or enrollee 
of a group health plan or group or individual health insurance 
coverage offered by a health insurance issuer who is to be 
furnished items or services by a nonparticipating provider or 
nonparticipating facility, is a document specified by the Sec-
retary, in consultation with the Secretary of Labor, through 
guidance that shall be signed by the participant, beneficiary, 
or enrollee before such items or services are furnished and 
that — 
‘‘(A) acknowledges (in clear and understandable lan-
guage) that the participant, beneficiary, or enrollee has 
been— 
‘‘(i) provided with the written notice under para-
graph (1)(A); 
‘‘(ii) informed that the payment of such charge 
by the participant, beneficiary, or enrollee may not 
accrue toward meeting any limitation that the plan 
or coverage places on cost-sharing, including an expla-
nation that such payment may not apply to an in- 
network deductible applied under the plan or coverage; 
and 
‘‘(iii) provided the opportunity to receive the writ-
ten notice under paragraph (1)(A) in the form selected 
by the participant, beneficiary or enrollee; and 
‘‘(B) documents the date on which the participant, bene-
ficiary, or enrollee received the written notice under para-
graph (1)(A) and the date on which the individual signed 
such consent to be furnished such items or services by 
such provider or facility. 
‘‘(4) RULE
OF
CONSTRUCTION.—The consent described in 
paragraph (3), with respect to a participant, beneficiary, or 
enrollee of a group health plan or group or individual health 
insurance coverage offered by a health insurance issuer, shall 
constitute only consent to the receipt of the information pro-
vided pursuant to this subsection and shall not constitute a 
contractual agreement of the participant, beneficiary, or 
enrollee to any estimated charge or amount included in such 
information. 
‘‘(e) RETENTION OF CERTAIN DOCUMENTS.—A nonparticipating 
facility (with respect to such facility or any nonparticipating pro-
vider at such facility) or a participating facility (with respect to 
nonparticipating providers at such facility) that obtains from a 
participant, beneficiary, or enrollee of a group health plan or group 
or individual health insurance coverage offered by a health insur-
ance issuer (or an authorized representative of such participant,
H. R. 133—1648 
‘‘SEC. 2799B–3. PROVIDER REQUIREMENTS WITH RESPECT TO DISCLO-
SURE ON PATIENT PROTECTIONS AGAINST BALANCE 
BILLING. 
‘‘Beginning not later than January 1, 2022, each health care 
provider and health care facility shall make publicly available, 
and (if applicable) post on a public website of such provider or 
facility and provide to individuals who are participants, bene-
ficiaries, or enrollees of a group health plan or group or individual 
health insurance coverage offered by a health insurance issuer 
a one-page notice (either postal or electronic mail, as specified 
by the participant, beneficiary, or enrollee) in clear and understand-
able language containing information on— 
‘‘(1) the requirements and prohibitions of such provider 
or facility under sections 2799B–1 and 2799B–2 (relating to 
prohibitions on balance billing in certain circumstances); 
‘‘(2) any other applicable State law requirements on such 
provider or facility regarding the amounts such provider or 
facility may, with respect to an item or service, charge a partici-
pant, beneficiary, or enrollee of a group health plan or group 
or individual health insurance coverage offered by a health 
insurance issuer with respect to which such provider or facility 
does not have a contractual relationship for furnishing such 
item or service under the plan or coverage, respectively, after 
receiving payment from the plan or coverage, respectively, for 
such item or service and any applicable cost-sharing payment 
from such participant, beneficiary, or enrollee; and 
‘‘(3) information on contacting appropriate State and Fed-
eral agencies in the case that an individual believes that such 
provider or facility has violated any requirement described 
in paragraph (1) or (2) with respect to such individual. 
‘‘SEC. 2799B–4. ENFORCEMENT. 
‘‘(a) STATE ENFORCEMENT.— 
‘‘(1) STATE AUTHORITY.—Each State may require a provider 
or health care facility (including a provider of air ambulance 
services) subject to the requirements of this part to satisfy 
such requirements applicable to the provider or facility. 
‘‘(2) FAILURE TO IMPLEMENT REQUIREMENTS.—In the case 
of a determination by the Secretary that a State has failed 
to substantially enforce the requirements to which paragraph 
(1) applies with respect to applicable providers and facilities 
in the State, the Secretary shall enforce such requirements 
under subsection (b) insofar as they relate to violations of 
such requirements occurring in such State. 
‘‘(3) NOTIFICATION OF APPLICABLE SECRETARY.—A State may 
notify the Secretary of Labor, Secretary of Health and Human 
Services, or the Secretary of the Treasury, as applicable, of 
instances of violations of sections 2799B–1, 2799B–2, or 2799B– 
5 with respect to participants, beneficiaries, or enrollees under 
a group health plan or group or individual health insurance 
coverage, as applicable offered by a health insurance issuer 
and any enforcement actions taken against providers or facili-
ties as a result of such violations, including the disposition 
of any such enforcement actions. 
‘‘(b) SECRETARIAL ENFORCEMENT AUTHORITY.— 
‘‘(1) IN
GENERAL.—If a provider or facility is found by 
the Secretary to be in violation of a requirement to which
H. R. 133—1649 
subsection (a)(1) applies, the Secretary may apply a civil mone-
tary penalty with respect to such provider or facility (including, 
as applicable, a provider of air ambulance services) in an 
amount not to exceed $10,000 per violation. The provisions 
of subsections (c) (with the exception of the first sentence of 
paragraph (1) of such subsection), (d), (e), (g), (h), (k), and 
(l) of section 1128A of the Social Security Act shall apply 
to a civil monetary penalty or assessment under this subsection 
in the same manner as such provisions apply to a penalty, 
assessment, or proceeding under subsection (a) of such section. 
‘‘(2) LIMITATION.—The provisions of paragraph (1) shall 
apply to enforcement of a provision (or provisions) specified 
in subsection (a)(1) only as provided under subsection (a)(2). 
‘‘(3) COMPLAINT
PROCESS.—The Secretary shall, through 
rulemaking, establish a process to receive consumer complaints 
of violations of such provisions and provide a response to such 
complaints within 60 days of receipt of such complaints. 
‘‘(4) EXCEPTION.—The Secretary shall waive the penalties 
described under paragraph (1) with respect to a facility or 
provider (including a provider of air ambulance services) who 
does not knowingly violate, and should not have reasonably 
known it violated, section 2799B–1 or 2799B–2 (or, in the 
case of a provider of air ambulance services, section 2799B– 
5) with respect to a participant, beneficiary, or enrollee, if 
such facility or provider, within 30 days of the violation, with-
draws the bill that was in violation of such provision and 
reimburses the health plan or enrollee, as applicable, in an 
amount equal to the difference between the amount billed and 
the amount allowed to be billed under the provision, plus 
interest, at an interest rate determined by the Secretary. 
‘‘(5) HARDSHIP EXEMPTION.—The Secretary may establish 
a hardship exemption to the penalties under this subsection. 
‘‘(c) CONTINUED APPLICABILITY OF STATE LAW.—The sections 
specified in subsection (a)(1) shall not be construed to supersede 
any provision of State law which establishes, implements, or con-
tinues in effect any requirement or prohibition except to the extent 
that such requirement or prohibition prevents the application of 
a requirement or prohibition of such a section.’’. 
(b) SECRETARY OF LABOR ENFORCEMENT.— 
(1) IN
GENERAL.—Part 5 of subtitle B of title I of the 
Employee Retirement Income Security Act of 1974 (29 U.S.C. 
1131 et seq.) is amended by adding at the end the following 
new section: 
‘‘SEC. 522. COORDINATION OF ENFORCEMENT REGARDING VIOLA-
TIONS OF CERTAIN HEALTH CARE PROVIDER REQUIRE-
MENTS; COMPLAINT PROCESS. 
‘‘(a) INVESTIGATING VIOLATIONS.—Upon receiving a notice from 
a State or the Secretary of Health and Human Services of violations 
of sections 2799B–1, 2799B–2, or 2799B–5 of the Public Health 
Service Act, the Secretary of Labor shall identify patterns of such 
violations with respect to participants or beneficiaries under a group 
health plan or group health insurance coverage offered by a health 
insurance issuer and conduct an investigation pursuant to section 
504 where appropriate, as determined by the Secretary. The Sec-
retary shall coordinate with States and the Secretary of Health 
and Human Services, in accordance with section 506 and with
H. R. 133—1650 
section 104 of Health Insurance Portability and Accountability Act 
of 1996, where appropriate, as determined by the Secretary, to 
ensure that appropriate measures have been taken to correct such 
violations retrospectively and prospectively with respect to partici-
pants or beneficiaries under a group health plan or group health 
insurance coverage offered by a health insurance issuer. 
‘‘(b) COMPLAINT PROCESS.— Not later than January 1, 2022, 
the Secretary shall ensure a process under which the Secretary— 
‘‘(1) may receive complaints from participants and bene-
ficiaries of group health plans or group health insurance cov-
erage offered by a health insurance issuer relating to alleged 
violations of the sections specified in subsection (a); and 
‘‘(2) transmits such complaints to States or the Secretary 
of Health and Human Services (as determined appropriate 
by the Secretary) for potential enforcement actions.’’. 
(2) TECHNICAL AMENDMENT.—The table of contents in sec-
tion 1 of the Employee Retirement Income Security Act of 
1974 (29 U.S.C. 1001 et seq.) is amended by inserting after 
the item relating to section 521 the following new item: 
‘‘Sec. 522. Coordination of enforcement regarding violations of certain health care 
provider requirements; complaint process.’’. 
SEC. 105. ENDING SURPRISE AIR AMBULANCE BILLS. 
(a) GROUP HEALTH PLANS AND INDIVIDUAL AND GROUP HEALTH 
INSURANCE COVERAGE.— 
(1) PHSA AMENDMENTS.—Part D of title XXVII of the Public 
Health Service Act, as added and amended by section 102 
and further amended by the previous provisions of this title, 
is further amended by inserting after section 2799A–1 the 
following: 
‘‘SEC. 2799A–2. ENDING SURPRISE AIR AMBULANCE BILLS. 
‘‘(a) IN GENERAL.—In the case of a participant, beneficiary, 
or enrollee who is in a group health plan or group or individual 
health insurance coverage offered by a health insurance issuer 
and who receives air ambulance services from a nonparticipating 
provider (as defined in section 2799A–1(a)(3)(G)) with respect to 
such plan or coverage, if such services would be covered if provided 
by a participating provider (as defined in such section) with respect 
to such plan or coverage— 
‘‘(1) the cost-sharing requirement with respect to such serv-
ices shall be the same requirement that would apply if such 
services were provided by such a participating provider, and 
any coinsurance or deductible shall be based on rates that 
would apply for such services if they were furnished by such 
a participating provider; 
‘‘(2) such cost-sharing amounts shall be counted towards 
the in-network deductible and in-network out-of-pocket max-
imum amount under the plan or coverage for the plan year 
(and such in-network deductible shall be applied) with respect 
to such items and services so furnished in the same manner 
as if such cost-sharing payments were with respect to items 
and services furnished by a participating provider; and 
‘‘(3) the group health plan or health insurance issuer, 
respectively, shall— 
‘‘(A) not later than 30 calendar days after the bill 
for such services is transmitted by such provider, send
H. R. 133—1651 
to the provider, an initial payment or notice of denial 
of payment; and 
‘‘(B) pay a total plan or coverage payment, in accord-
ance with, if applicable, subsection (b)(6), directly to such 
provider furnishing such services to such participant, bene-
ficiary, or enrollee that is, with application of any initial 
payment under subparagraph (A), equal to the amount 
by which the out-of-network rate (as defined in section 
2799A–1(a)(3)(K)) for such services and year involved 
exceeds the cost-sharing amount imposed under the plan 
or coverage, respectively, for such services (as determined 
in accordance with paragraphs (1) and (2)). 
‘‘(b) DETERMINATION OF OUT-OF-NETWORK RATES TO BE PAID 
BY HEALTH PLANS; INDEPENDENT DISPUTE RESOLUTION PROCESS.— 
‘‘(1) DETERMINATION THROUGH OPEN NEGOTIATION.— 
‘‘(A) IN GENERAL.—With respect to air ambulance serv-
ices furnished in a year by a nonparticipating provider, 
with respect to a group health plan or health insurance 
issuer offering group or individual health insurance cov-
erage, and for which a payment is required to be made 
by the plan or coverage pursuant to subsection (a)(3), the 
provider or plan or coverage may, during the 30-day period 
beginning on the day the provider receives an initial pay-
ment or a notice of denial of payment from the plan or 
coverage regarding a claim for payment for such service, 
initiate open negotiations under this paragraph between 
such provider and plan or coverage for purposes of deter-
mining, during the open negotiation period, an amount 
agreed on by such provider, and such plan or coverage 
for payment (including any cost-sharing) for such service. 
For purposes of this subsection, the open negotiation period, 
with respect to air ambulance services, is the 30-day period 
beginning on the date of initiation of the negotiations with 
respect to such services. 
‘‘(B) ACCESSING
INDEPENDENT
DISPUTE
RESOLUTION 
PROCESS IN CASE OF FAILED NEGOTIATIONS.—In the case 
of open negotiations pursuant to subparagraph (A), with 
respect to air ambulance services, that do not result in 
a determination of an amount of payment for such services 
by the last day of the open negotiation period described 
in such subparagraph with respect to such services, the 
provider or group health plan or health insurance issuer 
offering group or individual health insurance coverage that 
was party to such negotiations may, during the 4-day period 
beginning on the day after such open negotiation period, 
initiate the independent dispute resolution process under 
paragraph (2) with respect to such item or service. The 
independent dispute resolution process shall be initiated 
by a party pursuant to the previous sentence by submission 
to the other party and to the Secretary of a notification 
(containing such information as specified by the Secretary) 
and for purposes of this subsection, the date of initiation 
of such process shall be the date of such submission or 
such other date specified by the Secretary pursuant to 
regulations that is not later than the date of receipt of 
such notification by both the other party and the Secretary.