42 USC 300gg-137 – Patient-provider dispute resolution
(a) In general
Not later than January 1, 2022, the Secretary shall establish a process (in this subsection referred to as the “patient-provider dispute resolution process”) under which an uninsured individual, with respect to an item or service, who received, pursuant to section 300gg-136 of this title, from a health care provider or health care facility a good-faith estimate of the expected charges for furnishing such item or service to such individual and who after being furnished such item or service by such provider or facility is billed by such provider or facility for such item or service for charges that are substantially in excess of such estimate, may seek a determination from a selected dispute resolution entity for the charges to be paid by such individual (in lieu of such amount so billed) to such provider or facility for such item or service. For purposes of this subsection, the term “uninsured individual” means, with respect to an item or service, an individual who does not have benefits for such item or service under a group health plan, group or individual health insurance coverage offered by a health insurance issuer, Federal health care program (as defined in section 1320a-7b(f) of this title), or a health benefits plan under chapter 89 of title 5 (or an individual who has benefits for such item or service under a group health plan or individual or group health insurance coverage offered by a health insurance issuer, but who does not seek to have a claim for such item or service submitted to such plan or coverage).
(b) Selection of entities
Terms Used In 42 USC 300gg-137
- individual: shall include every infant member of the species homo sapiens who is born alive at any stage of development. See 1 USC 8
- Secretary: means the Secretary of Health and Human Services. See 42 USC 201
- Service: means the Public Health Service. See 42 USC 201
Under the patient-provider dispute resolution process, the Secretary shall, with respect to a determination sought by an individual under subsection (a), with respect to charges to be paid by such individual to a health care provider or health care facility described in such paragraph for an item or service furnished to such individual by such provider or facility, provide for—
(1) a method to select to make such determination an entity certified under subsection (d) that—
(A) is not a party to such determination or an employee or agent of such party;
(B) does not have a material familial, financial, or professional relationship with such a party; and
(C) does not otherwise have a conflict of interest with such a party (as determined by the Secretary); and
(2) the provision of a notification of such selection to the individual and the provider or facility (as applicable) party to such determination.
An entity selected pursuant to the previous sentence to make a determination described in such sentence shall be referred to in this subsection as the “selected dispute resolution entity” with respect to such determination.
(c) Administrative fee
The Secretary shall establish a fee to participate in the patient-provider dispute resolution process in such a manner as to not create a barrier to an uninsured individual’s access to such process.
(d) Certification
The Secretary shall establish or recognize a process to certify entities under this subparagraph.1 Such process shall ensure that an entity so certified satisfies at least the criteria specified in section 300gg-111(c) of this title.