IDR dispute status: Payment Determination Made

IDR reference number: DISP-1116682

ProPeer Resources, LLC has reviewed your Federal Independent Dispute Resolution (IDR) dispute with reference number DISP-1116682 and has determined that THE PROVIDER is the prevailing party in this dispute.

After considering all permissible information submitted by both parties, ProPeer Resources has determined that the out-of-network payment amount of $94,600.00 offered by THE PROVIDER is the appropriate out-of-network rate for the item or service 21932 on claim number *********** under this dispute.

ProPeer Resources, LLC based this determination on a review of the following:

THE PROVIDER submitted an offer of $94,600.00

Aetna submitted an offer of $1,117.50

Final Determination Rationale

Determination in favor of THE PROVIDER was made in this case. All submitted information was reviewed and investigated. Both the initiating party and non-initiating party provided evidence of good faith efforts to negotiate. There was notation, in the submitted information, that indicates the patient encounter was a “moderate/high severity” encounter with immediate and significant threat to life or physiologic function, which required a higher level of experience for this patient’s condition, and which required an urgent evaluation by the provider. The initiating and non- initiating party did provide a description of market share and additional information regarding location and services which weighed heavily into this determination. In addition, QPA was reviewed and considered in the determination. Lastly, for the billed service, the amount provided by the initiating party is supported. The information submitted by THE PROVIDER demonstrated the offer selected as the out-of-network rate, that is the offer that best represents qualified IDR item or service. Based on the preponderance of information THE PROVIDER is the prevailing party.

IDR dispute status: Payment Determination Made

IDR reference number: DISP-1039222

ProPeer Resources, LLC has reviewed your Federal Independent Dispute Resolution (IDR) dispute with reference number DISP-1039222 and has determined that THE PROVIDER is the prevailing party in this dispute.

After considering all permissible information submitted by both parties, ProPeer Resources Has determined that the out-of-network payment amount of $60,000.00 offered by THE PROVIDER is the appropriate out-of-network rate for the item or service 21932 on claim number *********** under this dispute.

ProPeer Resources, LLC based this determination on a review of the following:

THE PROVIDER submitted an offer of $60,000.00.

Aetna submitted an offer of $6,313.64.

Final Determination Rationale

Determination in favor of was made in this case. All submitted information was reviewed and investigated. Both the initiating party and non-initiating party provided evidence of good faith efforts to negotiate. There was notation, in the submitted information, that indicates the patient encounter was a “moderate/high severity” encounter with immediate and significant threat to life or physiologic function, which required a higher level of experience for this patient’s condition, and which required an urgent evaluation by the provider. The initiating and noninitiating party did provide a description of market share and additional information regarding location and services which weighed heavily into this determination. In addition, QPA was reviewed and considered in the determination. Lastly, for the billed service, the amount provided by the initiating party is supported. The information submitted by THE PROVIDER demonstrated the offer selected as the out-of-network rate, that is the offer that best represents a qualified IDR item or service. Based on the preponderance of information, THE PROVIDER is the prevailing party.

IDR dispute status: Payment Determination Made

IDR reference number: DISP-932450

ProPeer Resources, LLC has reviewed your Federal Independent Dispute Resolution (IDR) dispute with reference number DISP-932450 and has determined that THE PROVIDER is the prevailing party in this dispute.

After considering all permissible information submitted by both parties, ProPeer Resources, LLC has determined that the out-of-network payment amount of $45,409.40 offered by THE PROVIDER is the appropriate out-of-network rate for the item or service 15734 on claim number *********** under this dispute.

ProPeer Resources, LLC based this determination on a review of the following:

THE PROVIDER submitted an offer of $45,409.40

United Healthcare submitted an offer of $0.00

Final Determination Rationale

Determination in favor of  was made in this case. All submitted information was reviewed and investigated. Both the initiating party and non-initiating party provided evidence of good faith efforts to negotiate. The initiating party provided significant and pertinent information regarding the patient diagnosis and condition, the surgical procedure being performed, reasoning behind the necessity of the specialist as well as to why the surgical intervention was needed. They also provided a description of market share and additional information regarding location and services. All of these variances weighed heavily into this determination. In addition, QPA was reviewed and considered in the determination The information submitted by the initiating party demonstrated the offer selected as the out-of-network rate is the offer that best represents the value of the qualified IDR item or service. Based on the preponderance of information THE PROVIDER prevails.

IDR dispute status: Payment Determination Made

IDR reference number: DISP-749267

Medical Evaluators of Texas has reviewed your Federal Independent Dispute Resolution (IDR) dispute with reference number DISP-749267 and has determined that THE PROVIDER is the prevailing party in this dispute.

After considering all permissible information submitted by both parties, Medical Evaluators of Texas has determined that the out-of-network payment amount of $40,000.00 offered by  THE PROVIDER is the appropriate out-of-network rate for the item or service 19318 on claim number *********** under this dispute.

Medical Evaluators of Texas based this determination on a review of the following:

THE PROVIDER submitted an offer of $40,000.00.

Aetna Health Insurance submitted an offer of $2,010.70.

Final Determination Rationale

The information submitted by the Initiating Party (IP) and the Non-Initiating Party (NIP) in connection with their respective final payment offers for services rendered under CPT code 19318 in this claim no E3JM57XJ101 was thoroughly reviewed. The information included evidence that, within four (4) years of this claim, the NIP had paid the IP $44,000.00 for services rendered under this service code. The IP's final payment offer is closer to this amount. Therefore, the IP's final payment offer is chosen as best representing the value of the service rendered under this service code in this claim.

IDR dispute status: Payment Determination Made - Fees and Offer from One Party Only

IDR reference number: DISP-1050361

National Medical Reviews, Inc. has reviewed your Federal Independent Dispute Resolution (IDR) dispute with reference number DISP-1050361 and has determined that THE PROVIDER is the prevailing party in this dispute.

Because only one party, THE PROVIDER, submitted an offer and paid the corresponding fees, National Medical Reviews, Inc. has determined that the out-of-network payment amount of $81,250.00 offered by THE PROVIDER is the appropriate out-of-network rate for the item or service 21930 on claim number *********** under this dispute.

Final Determination Rationale

The certified IDR entity requested fees and offers from both parties; however, the certified IDR entity did not receive an offer and/or fees from one party. As a result, the certified IDR entity has found in favor of the party that submitted an offer and fees. National Medical Reviews, Inc. did not receive an offer and/or fees from Blue Cross Blue Shield. As a result, the certified IDR entity has found in favor of THE PROVIDER the only party to submit an offer and fees.