Provider submits a clean claim for out-of-network service.
Insurer has 30 calendar days to accept the bill and make an "initial payment" the amount insurer reasonably believes to be payment in full.
Within 30 business days of receiving the initial payment, the provider can trigger an open negotiation period, which lasts for 30 business days.
If parties agree on a rate prior to the end of the 30-day period, the negotiation is ended.
If parties do not agree and the 30-day open negotiation period is exhausted, either party may initiate the federal independent resolution process during the 4-business day period, which starts on the 31st day.
Parties have 3 business days to agree on an arbiter once the process is initiated, and the Secretary will select on their behalf within 3 additional business days if they don't agree.
The provider and insurer both have 10 business days to submit payment offers and supporting materials.
The arbiter makes a binding decision within 30 business days.
Any amount due from one party to the other must be paid within 30 calendar days and the arbiter must refund the prevailing party's certified IDR entity fee within 30 business days.
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