"Independent Dispute Resolution Process (Idrp) Request Form" - California

Independent Dispute Resolution Process (Idrp) Request Form is a legal document that was released by the California Department of Insurance - a government authority operating within California.

Form Details:

  • Released on September 1, 2017;
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Dave Jones
Insurance Commissioner
California Department of Insurance
Independent Dispute Resolution Process (IDRP) Request Form
Effective: September 1, 2017
Insurance Code § 10112.81
IDRP Request Number: ___________________________ (For Department Use Only)
Requesting Party Information
Requesting Party Name:
National Provider Identifier (NPI)
Number (If applicable)
- Requesting Party Contact
Person (if different from
Requesting Party):
- Requesting Party Address:
- Requesting Party Phone:
- Requesting Party Email:
Does Requesting Party designate an
☐Yes
☐No
1
Authorized Representative?
- Authorized Representative
Name
- Authorized Representative
Address:
- Authorized Representative
Phone:
- Authorized Representative
Email:
1
If the Requesting Party elects to designate an Authorized Representative, all subsequent
communication regarding this matter will be directed to the Authorized Representative unless the
Requesting Party notifies the Department in writing that it withdraws the designation of the Authorized
Representative. See Insurance Code § 10112.81(b)(4).
Dave Jones
Insurance Commissioner
California Department of Insurance
Independent Dispute Resolution Process (IDRP) Request Form
Effective: September 1, 2017
Insurance Code § 10112.81
IDRP Request Number: ___________________________ (For Department Use Only)
Requesting Party Information
Requesting Party Name:
National Provider Identifier (NPI)
Number (If applicable)
- Requesting Party Contact
Person (if different from
Requesting Party):
- Requesting Party Address:
- Requesting Party Phone:
- Requesting Party Email:
Does Requesting Party designate an
☐Yes
☐No
1
Authorized Representative?
- Authorized Representative
Name
- Authorized Representative
Address:
- Authorized Representative
Phone:
- Authorized Representative
Email:
1
If the Requesting Party elects to designate an Authorized Representative, all subsequent
communication regarding this matter will be directed to the Authorized Representative unless the
Requesting Party notifies the Department in writing that it withdraws the designation of the Authorized
Representative. See Insurance Code § 10112.81(b)(4).
Initial Determinations
Please respond to each of the below questions:
1. Do bundled claims associated with a single CPT code, or other
☐Yes
☐No
applicable procedure code system, exceed 50?
☐Yes
☐No
2. Are all claims for services rendered on or after July 1, 2017?
3. Does the IDRP request involves an insurer subject to the
☐Yes
☐No
jurisdiction of the California Department of Insurance
(“Department”)?
4. Does the IDRP request involves service(s) for emergency
☐Yes
☐No
2
services?
5. Does the IDRP request involves service(s) that were provided at a
☐Yes
☐No
contracting health facility by a noncontracting health
3
professional?
6. The IDRP request includes a dispute as to the proper procedure
☐Yes
☐No
code (such as CPT code) applied to the involved service(s)?
Claim Information
All claims in this IDRP Request Form must be for services rendered on or after July 1,
2017, provided by the same noncontracting individual health professional, provided at a
4
contracting health facility, and all bundled claims
must be for the same or similar
5
services.
You must provide this information on the IDRP Claim Information
Spreadsheet and upload the spreadsheet with this form. The spreadsheet may be
found at:
https://www.insurance.ca.gov/0250-insurers/0500-legal-info/0200-
regulations/HealthGuidance/index.cfm
Narrative Summary Justification
In addition to the below listed supporting documents, a completed application should
include a narrative summary justification that addresses all issues, information, and
arguments relevant to the Requesting Party’s suggested appropriate reimbursement
amount for the claims at issue. Only a single narrative summary justification will be
allowed even if claims are bundled. Do NOT provide proprietary or confidential at this
2
"Emergency services" shall have the same definition as in Health & Safety Code §1317.1
3
“Contracting health facility” shall have the same meaning as Insurance Code §10112.8(f)(1).
4
Up to 50 claims may be bundled in one IDRP Request Form.
5
See California Department of Insurance Implementation Guidance AB 72:2, “Independent Dispute
Resolution Process,” available at www. Insurance.ca.gov.
time. This form and supporting documentation will be shared with the Responding Party
and/or their authorized representative.
(Use additional pages as necessary.)
Provider Qualifications (To be completed by the Provider if the Provider is the
Requesting Party)
Length of Time in Practice:
Training and Qualifications:
Nature of Services Provided:
Fees usually charged for this type of
service (categorize by CPT code) by this
provider:
Other aspects of the economics of the
physician’s practice that are relevant:
Any other relevant qualifications:
Other Factors (optional)
The fees usually charged by similar
providers for the service in the
geographic area in which the services
were rendered:
The capacity of the insurer’s network to
provide access to the services subject to
IDRP:
Any unusual circumstances in the case:
Rates for the same services as listed in
the FAIR Health Database:
Any other relevant factor:
Required Supporting Documentation
• Claim Form(s) – If bundling claims, supporting documentation must be submitted
for each claim within a bundle. If each individual claim form does not provide the
information listed below, the following data table must be completed for that claim
so as to allow the Responding Party to identify the claim(s) and accurately
respond:
Subscriber Name
Patient Name
Patient ID#
Patient Date of Birth
(DOB)
Dates of Service (DOS)
Provider Name
Contracting Health Facility
Name
Claim Number
• Health Insurer Internal Dispute Resolution Determination Letter.
o Note: If a provider attempted an internal payment dispute resolution with
the health insurer, but did not receive a final determination letter from the
insurer and at least 45 working days have passed since the provider
submitted the request, plus 5 business days if the request was submitted
by mail, the provider may submit dated proof of the attempted internal
payment dispute resolution with the health insurer in lieu of a
determination letter.
• Explanation of Benefits or Remittance Advice.
• Any other documents Requesting Party considers relevant. It is the Requesting
Party’s responsibility to submit all information that it believes to be relevant to the
suggested appropriate reimbursement amount for the claim(s) at issue and that it
would like the IDRO to consider when making an IDRP decision. It is the
Requesting Party’s responsibility to explain the relevance of this documentation
in its narrative summary justification (above).
CONFIDENTIALITY: It is the responsibility of the Requesting Party to redact all
proprietary, confidential, or protected health information that should not be viewed by
the parties to the IDRP. Additionally, it is each IDRP participant’s responsibility to redact
from documents all identifying information relating to patient claims that are not the
subject of the IDRP.
SUBMIT
Submit IDRP Request Form, Claims Spreadsheet, and Supporting Documentation to
the Department as follows:
- Providers: Submit as an attachment through the electronic Health Care Provider
Complaint portal at https://cdiapps.insurance.ca.gov/HPP/login/.
- Insurers: Submit as an attachment through the electronic Consumer Complaint
portal at https://cdiapps.insurance.ca.gov/CP/login/.
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