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11_ppdr_walkthrough.md

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Rule 11, Patient-Provider Dispute Resolution (PPDR) walkthrough

For uninsured and self-pay patients whose final bill exceeds the Good Faith Estimate (GFE) they were entitled to receive. PPDR is the federal dispute resolution process created by the No Surprises Act. It is portal-driven, not letter-driven, so this is a rule with a checklist, not a template.

The kit treats PPDR as a separate track from other disputes because the protections that attach during PPDR (no collections, no late fees, no credit reporting) are uniquely valuable, and because the filing is on a strict 120-day clock.

The rule

If the patient meets all four of these conditions, file PPDR:

  1. The patient was uninsured or self-pay for the service in question.
  2. The patient was entitled to a Good Faith Estimate under 45 CFR § 149.610 (i.e., the service was scheduled at least three business days in advance, or the patient requested an estimate).
  3. The final bill from a single provider exceeds that provider's GFE by $400 or more.
  4. The patient is within 120 calendar days of receiving the bill.

If the patient is uninsured or self-pay and never received a GFE, that is itself a No Surprises Act violation. File a complaint at the No Surprises Help Desk (1-800-985-3059) before considering whether PPDR is the right track.

Why this is high-leverage

While a PPDR is pending:

  • The bill cannot be sent to collections.
  • The bill cannot accrue late fees.
  • The bill cannot be reported to consumer reporting agencies.

These protections are written into 45 CFR § 149.620 and apply for the duration of the dispute. Filing PPDR stops the collections clock on a self-pay bill more effectively than any other federal action.

The filing fee is $25, refundable if the Selected Dispute Resolution (SDR) entity rules in the patient's favor (i.e., determines the appropriate payment amount is below the billed amount).

Where the process lives

Checklist, what the patient needs before filing

The LLM walks the patient through this checklist. Each item should be collected, scanned, and named for upload.

1. The Good Faith Estimate (if one was provided)

If the patient received a GFE, usually delivered before scheduled service or, for self-pay scheduled services, automatically, locate it. Common forms:

  • A document titled "Good Faith Estimate," "GFE," or "estimate of charges"
  • A printed estimate from the provider's patient portal
  • An email or PDF attachment

The GFE shows the estimated total and lists each item or service with its associated estimated charge.

If the patient cannot find a GFE: did they get one? Did the provider not send one? Did the patient discard it? The PPDR process requires either the GFE itself or an attestation that the provider failed to provide one. Without one of those, the federal No Surprises Help Desk complaint is the better starting point.

2. The final bill

The bill that exceeds the GFE. PPDR is filed against a single provider's bill at a time. If the patient has bills from multiple providers (the hospital, the radiologist, the pathologist), each requires its own PPDR filing.

3. Evidence of self-pay or uninsured status

PPDR is for uninsured or self-pay patients. Self-pay means the patient chose not to submit the claim through insurance for this service, even if they have insurance. If the patient submitted to insurance and the claim was processed, PPDR is not available, the dispute path is internal appeal to the plan instead.

4. The $400 threshold per provider

Verify the math: final bill minus GFE estimate for that same provider equals at least $400. Hospital bills often have separate line items from separately-billed providers (anesthesia, radiology, pathology); each provider's $400 threshold is calculated separately against that provider's GFE line.

5. Date the bill was received

The 120-day clock runs from when the patient received the bill, not when the provider sent it. Use the postmark date if known; otherwise the patient's best estimate. This is what the PPDR portal asks for and is what triggers the deadline.

6. $25 filing fee

Pay at the portal. Refundable if the SDR rules favorably.

How PPDR works after filing

The compressed sequence:

  1. Patient files at the federal IDR portal, attaching the GFE (if any), the final bill, and basic identifying information.
  2. CMS selects an SDR entity (a third-party arbitrator certified by HHS). Patient and provider receive notice.
  3. Provider has 10 business days to submit their evidence: original GFE, justification for the billed amount, supporting documentation.
  4. Patient may submit additional evidence in response.
  5. SDR entity reviews and issues a decision, typically within 30 days of receiving both parties' submissions. The SDR's determination of the appropriate amount is binding on the provider.
  6. Provider must adjust the bill to the SDR-determined amount within 30 days of the decision.
  7. If SDR rules below the billed amount: patient's $25 filing fee is refunded. Patient owes only the SDR-determined amount.
  8. If SDR rules at the billed amount: patient owes the billed amount, but the collections-pause and credit-report protections that applied during the dispute are now lifted.

What evidence the patient should submit

Beyond the basic filing, the SDR entity will weigh:

  1. The provider's own published cash price (from the hospital's Hospital Price Transparency machine-readable file, if applicable, see templates/complaint_cms_hpt.md for how to compel one).
  2. Reasonable fair-market data for the CPT codes in question (Turquoise Health, FAIR Health Consumer; see references/resources.md).
  3. Medicare allowable rates for the same CPT codes (CMS Physician Fee Schedule Lookup).
  4. The GFE itself as the patient's reasonable expectation.
  5. Any clinical-necessity context, if the bill includes services beyond what was on the GFE because of an intra-procedure decision, the patient should not be liable for those add-ons absent the patient's informed consent to a new GFE.

When PPDR is the wrong tool

  • The patient has insurance and used it. PPDR is for self-pay. Use internal-appeal templates instead.
  • The disputed amount is below $400 above the GFE. PPDR doesn't apply; use general dispute templates.
  • The 120-day clock has run. Same; use general dispute templates and consider whether the underlying issue is also a GFE-failure-to-provide complaint to CMS.
  • The dispute is about a service not on the GFE at all. If the bill includes a service the patient didn't consent to and that wasn't on the GFE, that's a services-not-received finding and a separate dispute under letter_initial_dispute.md.

Parallel actions

  • CMS complaint if the GFE was deficient or missing: 1-800-985-3059, or cms.gov/medical-bill-rights/help/submit-a-complaint. Failure to provide a GFE is its own NSA violation independent of the PPDR process.
  • State insurance department: for fully-insured plans where the patient is also pursuing an internal appeal, the state complaint creates parallel pressure.
  • Hospital Price Transparency complaint: if the hospital's MRF is non-compliant, file the parallel CMS HPT complaint. Use the MRF to anchor the patient's PPDR submission.

Follow-up

The LLM logs the filing with action_type = "ppdr_filed". Set response_due_by to 60 days from filing (typical end-to-end PPDR resolution timeline). Note in notes field that collections-pause and credit-protection apply during the pendency. If the patient receives any collections contact during pendency, that contact itself violates federal law, log a separate finding and file an immediate complaint with the No Surprises Help Desk.

Related rules

  • [[01_never_pay_first]], the general principle PPDR enforces for self-pay patients
  • [[04_no_surprises_act]], PPDR's parent framework
  • [[09_pricing_resources]], the price data that anchors the patient's PPDR submission