New Hampshire IDR Arbitration For Medical Revenue Recovery

New Hampshire Surprise Billing Law (SBL) Overview

The New Hampshire Surprise Billing Law (SBL) became effective on July 1, 2018, and is codified under New Hampshire Revised Statutes Annotated (NH RSA) Title XXX 329:31-b(III). This law regulates reimbursement for certain out-of-network (OON) services and outlines a dispute resolution process for providers and payers.

Key Provisions of the New Hampshire SBL

1. Reimbursement Standard:
   • Payments for OON services are required to reflect a “commercially reasonable value” for the services provided.
2. Dispute Resolution:
   • Pre-Arbitration Efforts:
     • Both parties must use their best efforts to resolve disputes before initiating arbitration.
     • However, the law does not specify a required timeline for this resolution process.
   • Arbitration Evidence:
     • Arbitrators can consider good payment proofs (evidence of reasonable payment rates) during the arbitration process.

State and Federal Coordination

1. Specified State Laws:
   • NH RSA Title XXX 329:31-b(III) applies specifically to the following scenarios:
     • Services Covered:
       • Anesthesiology, radiology, emergency medicine, or pathology services.
     • Provider Settings:
       • Services rendered by OON providers in in-network hospitals or ambulatory surgical centers.
     • Plans Covered:
       • Managed care plans operating within New Hampshire.
2. Federal Independent Dispute Resolution (IDR):
   • The federal IDR process applies in cases not governed by NH RSA Title XXX 329:31-b(III), such as:
     • Nonparticipating Providers and Facilities:
       • Claims involving OON providers and emergency facilities that do not fall under the New Hampshire law.
     • Air Ambulance Services:
       • Claims for air ambulance services by nonparticipating providers.
   • Governed under Section 2799A-1(c) and 45 CFR 149.510, the federal IDR process determines OON rates for applicable items and services.

CMS Clarifications

In a letter from CMS to the Governor of New Hampshire (December 22, 2021), the following points were highlighted:

1. No All-Payer Model Agreement:
   • New Hampshire does not have an applicable All-Payer Model Agreement for OON rate determination.
2. Application of State Law:
   • NH RSA Title XXX 329:31-b(III) is recognized as a specified state law for determining OON rates in certain cases, particularly for managed care plans involving specific medical specialties in in-network facilities.
3. Federal Oversight:
   • CMS enforces the outcomes of the federal IDR process for cases where NH RSA Title XXX 329:31-b(III) does not apply.

This dual approach ensures that both state-specific and federally mandated protections are in place to address surprise billing and OON reimbursement disputes.