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:

Imported — Case created from CSV/Excel upload
Screening — Eligibility checklist in progress
Eligible — All eligibility checks passed
Assigned — Arbitrator assigned to the dispute
In Progress — At least one sealed offer submitted
Determined — Arbitrator has selected the winning offer
Closed — Case finalized

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 to see the expected format and column names — a "Download CSV Template" button is available on the Import page with 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 system validates each row (including CPT code format validation — codes must be 4–5 alphanumeric characters), creates dispute records for valid rows, and reports validation errors for invalid rows. Partial imports are supported — valid rows are imported even if other rows fail.

If a CMS reference number already exists in your account, that row will be 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.

Supports files up to 50MB or approximately 50,000 rows per upload. Imports run as background tasks, so the UI does not block during processing.

Required 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)	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
Jurisdiction	jurisdiction (defaults to "federal")	No

Note: CPT codes are validated for correct format (4–5 alphanumeric characters). Codes that don't match this format are flagged as errors. However, codes are not validated against the AMA CPT database (this requires a data licensing agreement). Verify accuracy against your own CPT references.

Permissions

Tenant admins, arbitrators, and case managers can perform imports. 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 — a 6-item manual checklist:

Jurisdiction confirmed
Batching/bundling compliant
Timelines met
Open negotiations completed
Required disclosures received
QPA disclosed

If all six checks pass and are saved, the dispute status automatically advances to "Eligible." If any are unchecked, it stays in "Screening." A non-initiating party can formally challenge eligibility with a reason through the eligibility challenge endpoint.

Jurisdiction selection

The arbitrator selects the jurisdiction manually — either Federal (No Surprises Act, 45 CFR Part 149) or Texas (Insurance Code Chapter 146). This affects:

Which statutory factors are shown 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.

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:

Once submitted, an offer is locked and cannot be changed
Parties and case managers cannot see the opposing party's offer until both are submitted
Only arbitrators and tenant admins can view both offers
When both offers are in, the arbitrator sees them side by side on the Determination tab
The arbitrator must pick one offer exactly as written — custom amounts are not allowed

Organizations can set an optional offer deadline per dispute (a datetime field on the dispute detail page). When set, the platform sends automatic reminder notifications 24 hours before the deadline and urgent alerts when deadlines pass. Notifications go to the assigned arbitrator. Deadlines are checked daily at 8:00 AM UTC. If no deadline is set, offer submission remains open until both parties have submitted.

Statutory factor analysis

The Factor Analysis tab presents all 7 statutory factors. For each factor, the arbitrator enters free-text findings and a supported/not-supported toggle indicating whether the evidence favors the provider or the plan.

The 7 statutory factors

#	Factor	Jurisdiction
1	Medical Necessity	All
2	Provider Qualifications and Experience	All
3	Patient-Specific Factors	All (Texas emphasis)
4	Good Faith Contracting Efforts	Federal only
5	Market Share	Federal only
6	Quality and Outcome Measurements	Federal only
7	Additional Factors	All

Factor analysis auto-saves — the arbitrator can work through factors incrementally across multiple sessions. All required statutory factors must have substantive 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 fields are displayed
Texas cases: Fair Health 50th and 80th percentile fields are displayed

Making a determination

On the Determination tab, the arbitrator selects the winning offer (provider or plan), enters a required rationale, and clicks Confirm Determination. This action:

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"

Important: Determinations are final and binding once confirmed. In the rare case of a clerical error, a system administrator can issue a formal correction with a documented reason. The original determination and all corrections are preserved in a complete audit trail — including the original values, corrected values, correcting administrator's identity, and timestamp. The assigned arbitrator is notified when a correction is made. This workflow is restricted to system administrators only; arbitrators and tenant admins cannot self-correct.

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 an AI-powered 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, date and place of service
Full financial history (billed charges, allowed amount, patient responsibility)
Benchmark data (QPA or Fair Health percentiles)
Both final offers with amounts
All factor analysis findings with supported/not-supported flags
Selected offer party and rationale

Regenerating with instructions

A free-text field lets the arbitrator provide additional guidance — 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.

Language

Opinions are generated in the arbitrator's configured language (English by default; other languages available with the AI Translation add-on). Content is generated directly in the target language — not translated after generation.

Token usage

A typical opinion generation consumes 4,000–8,000 AI tokens depending on case complexity. Token usage counts against the tenant's monthly AI token allocation. 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.

CMS compliance reporting

The IDR Reports page generates quarterly CSV exports aligned to the CMS Public Use File format. 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. Automatic quarterly reminders are sent to account administrators at the start of each reporting period — on the 5th of January, April, July, and October. The notification includes the relevant quarter name and directs them to the IDR Reports page.

Arbitrator performance metrics

The IDR Reports page includes a per-arbitrator performance table showing:

Total cases completed
Average days from assignment to determination
Provider win rate (percentage of provider-selected determinations)
Plan win rate

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 CPT code validation against AMA database (format validation only — requires a data licensing agreement)
No Fair Health or QPA database integration — values entered manually
Panel arbitration workflow UI not yet available (data model ready — see below)

Planned enhancements

CPT code description auto-population from AMA database (requires data licensing)
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 supports multiple arbitrators per dispute; workflow in development for state-level programs)

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