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Spotlight Mandate: New independent dispute resolution process for out-of-network provider reimbursement disputes

This regulation will give plans and out-of-network providers (including air ambulance providers) 30 days to negotiate a final payment amount after an initial payment or a denial by the plan. If an agreement cannot be reached, this regulation sets timelines for the independent dispute resolution (IDR) process and permits plans and out-of-network providers to continue negotiations until the IDR entity makes a final, binding decision. Resolution of the out-of-network payment amount does not impact the member, and the member will not be balance billed.

Who it applies to: Fully insured group health plans, self-funded group plans and individual policies – including all grandfathered plans.

Effective date: Plan years beginning on or after Jan. 1, 2022

Action required: No member or employer group action is needed at this time; changes will be made within BCBSND systems.