Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 365 - STANDARDS FOR INDEPENDENT DISPUTE RESOLUTION OF EMERGENCY MEDICAL SERVICE BILLS › Section 031-365-4 - Application for Selection as an IDRE

Current through 2024-29, July 17, 2024
An entity applying for selection as an IDRE shall submit to
				  the Superintendent an application on the form prescribed by the Superintendent.
				  The application must describe the proposed IDRE's organizational structure and
				  capability to operate a statewide IDR process, including:
1. copies of its certificate of incorporation
				or articles of organization, bylaws or operating agreement, and, as applicable,
				those of its holding company or parent company;
2. its organizational chart;
3. the names and biographical information
				relevant to the business of independent dispute resolution services for all
				members of its board of directors, its officers, and its executives, including
				their respective roles, and responsibilities;
4. the names of all corporations and
				organizations that it controls, is controlled by, or is under common control
				with, and the nature and extent of that control;
5. its policies and procedures governing all
				aspects of the IDR process, including at a minimum:
A. a description and a chart or diagram of
				the sequence of steps through which a dispute will move from receipt through
				notification of the dispute determination to interested parties;
B. procedures for ensuring that the
				arbitrator assigned to a dispute has no prohibited material financial, material
				personal, or material professional affiliation. These procedures must include a
				requirement for a signed attestation by each arbitrator assigned to review a
				dispute;
C. procedures to ensure
				that each dispute is reviewed by a neutral and impartial arbitrator with
				training and experience in healthcare billing, reimbursement, and usual and
				customary charges;
D. procedures
				for reporting and reviewing an arbitrator's conflicts of interest, for
				determining whether there is a conflict of interest, and for assigning or
				reassigning an IDR where a conflict is identified;
E. procedures to ensure that reviews are
				conducted within the time frames specified in this rule and any required
				notices are provided in a timely manner;
F. procedures to ensure the confidentiality
				of personal health information, personally identifiable information, and review
				materials;
G. procedures to ensure
				adherence to the requirements of this rule by any contractor, subcontractor,
				agent, or employee;
H. a
				description of the following:
(1) its ability
				to provide review services statewide;
(2) the qualifications the arbitrators
				retained to review payment disputes, including current and past employment
				history, as applicable;
(3) the
				procedures employed to ensure that arbitrators reviewing payment disputes are:
(a) trained in the principles of dispute
				resolution and the procedures and standards of the proposed IDRE;
(b) knowledgeable about the health care
				service which is the subject of the payment dispute under review; and
(c) trained and experienced in health care
				billing, reimbursement and usual and customary charges;
(4) the methods of recruiting and selecting
				neutral and impartial arbitrators and matching such reviewers to specific
				cases;
I. its
				organizational arrangements and ongoing procedures for the identification,
				evaluation, resolution, and follow-up of potential and actual problems in
				payment dispute reviews; and the maintenance of program standards pursuant to
				this subdivision;
J. written
				procedures documenting that:
(1) appropriate
				personnel are reasonably accessible at least 40 hours per week during normal
				business hours to discuss the dispute resolution process and to allow response
				to telephone requests; and
(2) a
				response to an answered call or recorded message shall be made no later than
				the next business day after the call was received;
K. its fees, which must include disclosure
				of:
(1) the total amount that it will charge
				for reviews, inclusive of indirect costs, administrative fees and incidental
				expenses;
(2) the pro-rated fee
				that will be charged when a good faith negotiation directed by the proposed
				IDRE results in a settlement between a carrier and a provider;
(3) an application processing fee if the
				dispute is determined by the proposed IDRE to be ineligible for
				review;
(4) the fee that will be
				charged to the provider when an eligible patient requests an IDR;
(5) the methodology used to calculate all
				fees; and
(6) any fee charged for
				the configuration of a portal to receive IDR applications from out-of-network
				providers and eligible patients;
L. how it provides requisite notifications,
				screens for material affiliations, responds during normal business hours to
				inquiries from the State and from interested persons regarding the dispute
				resolution process; and
M. such
				other information as the Superintendent may require.