Arbitration
Medical Billing IDR
Vilulia Arbitrate includes a Medical Billing Independent Dispute Resolution (IDR) module for processing disputes under the federal No Surprises Act and state-level programs. IDR is included in Professional and Enterprise tiers at no additional monthly cost. The only IDR-specific charge is a per-case determination fee of $75 (custom pricing available for Enterprise contracts).
What you'll learn
- How to import cases from the CMS portal
- The end-to-end IDR workflow from import to determination
- How eligibility screening works
- How baseball-style sealed offers are managed
- How to complete the statutory factor analysis
- How AI opinion drafting works
- CMS compliance reporting
Availability
Medical Billing IDR is available on Professional and Enterprise tiers of Vilulia Arbitrate and Vilulia Complete (Bundle). It is not available on Starter tier or in Vilulia Mediate. The module interface is available in all 5 supported languages: English, Spanish, French, German, and Portuguese.
End-to-end workflow
The IDR workflow follows these statuses in order:
- Imported — Case created from CSV/Excel upload or manual entry
- Screening — Eligibility checklist in progress
- Eligible — All required eligibility checks passed
- Ineligible — Dispute ruled ineligible (can transition to Closed)
- Assigned — Arbitrator assigned; auto-set when an eligible dispute is assigned
- In Progress — Both sealed offers submitted
- Determined — Arbitrator has selected the winning offer
- Closed — Case finalized
The "Determined" status can only be set through the /determineendpoint — direct status updates to "determined" via the PATCH endpoint are blocked. Disputes in terminal statuses ("determined" or "closed") cannot be updated.
Disputes in "Imported," "Screening," or "Eligible" status with no activity for 90+ days are automatically closed by a weekly background task (runs Sundays at 3:00 AM UTC). Auto-closed disputes are marked with the reason "No activity for 90+ days." Disputes that have been assigned to an arbitrator or are in active progress are not affected by auto-expiration.
Importing cases
Staff exports assigned cases from the CMS portal as CSV or Excel files (.csv, .xlsx). Download the CSV template before your first import — a "Download CSV Template" button is available on the Import page. The template includes correct column headers and two sample rows demonstrating proper formatting for CPT codes, dates, ZIP codes, and financial amounts.
Navigate to the IDR Import page and upload the file. The import runs as a background Celery task — the UI does not block during processing. Check the import batch status page to see results: total rows, successful imports, failed imports, and per-row validation errors. Valid rows are imported even if other rows fail (partial imports are supported).
If a CMS reference number already exists in your account, that row is skipped and flagged as a duplicate. Within-file duplicates (same CMS reference appearing twice in one CSV) are also caught — the first occurrence imports and subsequent ones are flagged. Files up to 50 MB are supported.
Required and accepted fields
| Field | Accepted column names | Required |
|---|---|---|
| Date of service | date_of_service, dos, service_date | Yes |
| Geographic ZIP | geographic_zip, zip, zip_code, geo_zip | Yes |
| CPT codes | cpt_codes, cpt, cpt_code (comma-separated or structured) | Yes (at least one) |
| Provider name | provider_name, provider | Yes |
| Health plan name | health_plan_name, health_plan, plan_name, insurer | Yes |
| CMS reference number | cms_reference_number, cms_ref, reference_number, dispute_id | No |
| Billed charges | billed_charges, billed_amount, charges | No |
| Allowed amount | initial_allowed_amount, allowed_amount, plan_payment | No |
| Patient responsibility | patient_responsibility | No |
| QPA amount | qpa_amount | No |
| Provider entity type | provider_entity_type | No |
| Health plan entity type | health_plan_entity_type | No |
| Place of service | place_of_service | No |
| Patient identifier | patient_identifier | No |
| Jurisdiction | jurisdiction (defaults to "federal") | No |
Note: CPT codes are validated for format. The system also maintains a CPT code registry that can be searched and validated against. If your organization holds an AMA CPT license, you can self-certify via the IDR Settings page to enable CPT code description auto-population in the IDR brief summary AI tool. Without AMA certification, code descriptions are not displayed. Verify CPT code accuracy against your own references.
Permissions
Tenant admins and case managers can perform bulk imports. Arbitrators can also import. In a busy IDR operation, case managers typically handle bulk imports while arbitrators focus on determinations.
Eligibility screening
After import, an arbitrator or case manager opens the dispute and completes the Eligibility Screening tab. The checklist is stored as a structured JSON object; any checklist structure can be saved, and auto-advancement to "Eligible" occurs when all items in the required key of the checklist are set to true.
If any required check is missing, the dispute stays in "Screening." A non-initiating party can formally challenge eligibility through the eligibility challenge endpoint — this reverts an "Eligible" dispute back to "Screening" for re-evaluation. An arbitrator or admin can then issue a formal eligibility ruling (eligible or ineligible) through the eligibility ruling endpoint.
Jurisdiction selection
The jurisdiction is set per dispute — either Federal (No Surprises Act, 45 CFR Part 149) or Texas (Insurance Code). This affects:
- Which statutory factors are required in the Factor Analysis tab
- Which benchmark data fields are displayed (QPA for federal, Fair Health percentiles for Texas)
- Which governing authority the AI cites in opinion drafts
Additional state programs will be added as the regulatory landscape expands.
Arbitrator assignment
Tenant admins and case managers assign an arbitrator to a dispute from the dispute detail page. The assigned user must hold the arbitratorrole within the tenant. When an eligible dispute is assigned, its status automatically advances to "Assigned." The assigned arbitrator receives an in-platform notification. The assignment endpoint validates that the user exists in the tenant and has the correct role before accepting the assignment.
Sealed offers (baseball-style arbitration)
Each party (provider and health plan) submits their sealed final offer independently through the Offers tab. Critical rules enforced by the platform:
- Offers can only be submitted when the dispute is in "Assigned" or "In Progress" status
- Once submitted, an offer is locked and cannot be changed
- Case managers cannot see either offer until both are submitted
- Only arbitrators and tenant admins can see both offers at any time
- When both offers are submitted, the dispute automatically advances to "In Progress" and the arbitrator is notified
- The arbitrator must pick one offer exactly as written — custom amounts are not allowed
An optional offer deadline (ISO datetime) can be set per dispute. Deadline notifications and urgency alerts are sent to the assigned arbitrator. If no deadline is set, offer submission remains open until both parties have submitted.
Statutory factor analysis
The Factor Analysis tab presents the statutory factors. For each factor, the arbitrator enters free-text findings and a supported/not-supported boolean indicating whether the evidence favors the provider or the plan.
The statutory factors
| # | Factor | Jurisdiction |
|---|---|---|
| 1 | Medical Necessity | All (required for determination) |
| 2 | Provider Qualifications and Experience | All (required for determination) |
| 3 | Patient-Specific Factors | All |
| 4 | Good Faith Contracting Efforts | Federal only (required for determination) |
| 5 | Market Share | Federal only (required for determination) |
| 6 | Quality and Outcome Measurements | Federal only (required for determination) |
| 7 | Additional Factors | All |
Factor analysis auto-saves — the arbitrator can work through factors incrementally across multiple sessions. Required factors must have substantive text findings before a determination can be confirmed. For all cases: Medical Necessity and Provider Qualifications are required. For federal cases: Good Faith Contracting, Market Share, and Quality/Outcome Measurements are additionally required. If any required factor is missing or empty, the determination is blocked with a specific error message identifying the incomplete factor.
Benchmark data
QPA (Qualifying Payment Amount) and Fair Health percentile values are entered manually per dispute, either during CSV import or through the dispute detail UI. The platform does not integrate with external QPA or Fair Health databases.
- Federal cases: QPA field is displayed
- Texas cases: Fair Health 50th and 80th percentile fields are displayed
Making a determination
The determine endpoint requires:
- Dispute must be in "In Progress" status
- Both provider and plan offers must be submitted
- Factor analysis record must exist
- All required factors for the jurisdiction must have substantive text
- An overall rationale must be provided
When all conditions are met, confirming the determination:
- Sets the awarded amount from the selected party's offer
- Records the determination date
- Triggers the $75 per-case metered billing charge via Stripe
- Advances the dispute status to "Determined"
- Notifies all case participants (or the arbitrator directly if no case is linked)
Important: Determinations are final once confirmed. In the rare case of a clerical error, a system administrator (not a tenant admin or arbitrator) can issue a formal correction with a documented reason. The original determination and all corrections are preserved in the dispute's correction history — including original values, corrected values, correcting administrator's identity, and timestamp. The assigned arbitrator is notified when a correction is made.
If both parties submit identical offer amounts, the arbitrator still selects one party's offer. The selection determines which party "won" for CMS reporting purposes.
AI opinion drafting
After determination, the arbitrator can generate a starting-point draft opinion on the Opinion tab. The AI pulls exclusively from structured case data — not from uploaded documents. Inputs include:
- Jurisdiction, party names and entity types
- CPT codes with descriptions (if AMA-licensed), date and place of service
- Full financial history (billed charges, allowed amount, patient responsibility)
- Benchmark data (QPA or Fair Health percentiles, as applicable)
- Both final offers with amounts
- All factor analysis findings with supported/not-supported flags
- Selected offer party and rationale
The generated text is a starting-point draft for arbitrator review and editing — it is not a final work product and must be reviewed for accuracy before use.
Regenerating with instructions
A free-text field accepts additional guidance when regenerating — for example, "emphasize the provider's board certification" or "shorten the patient-specific factors section." Instructions are appended to the AI prompt alongside the structured case data.
Version tracking
Each generation creates a new draft version with an incrementing version number. All versions are stored and viewable on the Opinion tab. The export function always uses the latest version.
Token usage
Opinion generation token usage is tracked against the tenant's monthly AI token allocation and recorded in the audit log with the AI model used. Heavy IDR users may need the AI Tokens Overage add-on.
Exporting opinions
The Opinion tab includes a Word document export option. Export produces a professionally formatted Word document with your entity name in the header, an "Arbitration Opinion and Award" title with jurisdiction subtitle, all 10 standard sections with Roman numeral headings (Authority, Parties, Services in Dispute, Financial History, Evidence Standard, Benchmark Analysis, Statutory Factors, Offer Selection, Award, Arbitrator Certification), financial data formatted as tables, a signature block with arbitrator name and date placeholder, page numbers in the footer, and professional fonts with 1-inch margins — ready for review and signing. Exports are delivered as a pre-signed S3 URL.
CMS compliance reporting
The IDR Reports page generates quarterly CSV exports. Select a year and quarter to export. Fields include:
- CMS reference number, date of service, CPT codes, geographic ZIP
- Jurisdiction, provider name, health plan name
- Billed charges, QPA amount
- Provider and plan final offers
- Selected offer party, awarded amount, determination date
CMS exports are always in English regardless of the user's locale setting. Quarterly reporting access is restricted to tenant admins and case managers.
Arbitrator performance metrics
The IDR Reports page includes a per-arbitrator performance table showing:
- Total disputes assigned and total determinations completed
- Average days from dispute creation to determination
- Provider win count and plan win count
IDR dashboard
The IDR dashboard provides aggregate stats for the tenant:
- Total disputes and counts by status
- Counts by jurisdiction (federal vs. Texas)
- Average days to determination
- Eligibility challenge rate
- Top 10 CPT codes by frequency
Audit trail
The system captures milestone events for URAC accreditation support: dispute creation (including import source), every status transition, arbitrator assignment, offer submissions with timestamps and amounts, eligibility challenges and rulings, factor analysis saves, determination confirmation, and opinion draft generation (with AI model and token count). Each event records the acting user and timestamp.
HIPAA considerations
IDR disputes involve Protected Health Information (patient identifiers, dates of service, medical procedure codes, billing data). The base platform provides encryption at rest and in transit. For full HIPAA compliance — including BAA coverage, enhanced audit logging, access controls, and breach notification — enable the HIPAA Basic or HIPAA Enhanced add-on.
Billing
The $75 per-case determination fee is charged automatically via Stripe metered billing when the arbitrator confirms the determination. The charge appears on the tenant's next Stripe invoice alongside other usage-based charges (SMS, storage, blockchain, AI tokens). Enterprise pricing is custom-negotiated and can be discounted or waived.
Known limitations
- No Fair Health or QPA database integration — values entered manually
- AMA CPT description auto-population requires the tenant to self-certify an AMA license in IDR Settings
- Panel arbitration workflow UI not yet available (data model supports multiple arbitrators per dispute)
Planned enhancements
- Fair Health API integration (requires commercial licensing agreement)
- Additional state jurisdiction support beyond Federal and Texas
- Direct CMS API integration (blocked on CMS — no public API exists)
- Panel arbitration workflow UI (data model is ready; workflow in development for state-level programs)
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