Overview

As of January 1, 2022, air ambulance service providers are subject to the No Surprises Act (NSA), which protects patients from surprise medical bills from out-of-network air ambulance service providers and removes them from payment disputes between plans and providers. A stated congressional goal in the Act is to reduce costs of emergency care to patients by disallowing balance billing patients for more than what would be their deductible and shared costs in their insurance plan and to push providers and payors to use the median of charges.  Balance billing is generally prohibited for air ambulance services.* Likewise, the final charges to the payor are limited to the lessor of the billed amount or a qualifying payment amount (QPA), whichever is less. Cost sharing can never exceed the amount the patient would otherwise pay if the services were rendered by a participating provider.

In August 2022, HHS issued a rule clarifying that the QPA should not be considered the presumptive amount and that IDR entities should select the offer that best represents the value of the item or service under dispute after considering the QPA and all permissible information submitted by the parties, with an emphasis on quantifying and documenting the six additional considerations included in the Act.

Air ambulance services vary based on scope of practice, patient populations served, and geographical coverage area, which translate into varying investments in clinical and aviation capabilities. These capabilities have a direct correlation to the quality and safety of patient care, as well as the associated costs for each patient transport. In addition, the complexity of managing individual patients varies significantly. A STEMI patient with minimal interventions at bedside or during transport for example is a very different patient than a patient requiring complex resuscitation at the bedside and ongoing resuscitation ECMO during transport.

The Payment Evaluation Tool created by ACCT provides a systematic approach for a provider to transparently develop and defend their proposed service price using the factors/attributes outlined in the No Surprises Act for the purposes of open negotiation with an out-of-network payor and to apply the same methodology to the independent dispute resolution (IDR) process if the open negotiation process should fail.

Navigating the No Surprises Act

The total amount paid to the provider/ facility must be based on the “recognized amount,” which is (in order of priority):

  • An amount agreed upon by the plan/issuer and provider.
  • An amount determined by an applicable All-Payer Model (APM) Agreement
  • An amount determined by specified state law
  • An amount determined by an independent dispute resolution (IDR) entity

The plan/issuer must provide the qualified payment amount (QPA) for each item/service as part of the initial payment or notice of denial of payment, along with a statement certifying that the QPA applies and was determined in compliance with the methodology outlined in the regulations. In a nutshell, the QPA is a single payer’s median contracted rate for the same or a similar service in a particular geographic region. Upon request, the payor must also provide information about QPA pricing, including whether it includes non-fee-for-service rates, was based on a derived amount, which related service codes were used to price new codes, and what database was used (if relevant), and any APM-based rates that were not included in calculating the QPA. Notably, they are not required to replicate how the QPA was calculated or provide the original raw data used to calculate it.**

If a payment amount cannot be decided on between the payer and provider during the required 30-day open negotiation period, either party can initiate the federal IDR process. The receiving party has three business days to respond to the initial notice. Both parties then have 10 business days to submit their respective offers along with any supporting information or documentation and applicable fees. The IDR Entity will then select the offer that “best represents the value of the air ambulance service under dispute after considering the QPA and all permissible information submitted by the parties.”

The arbitrator is required to consider additional criteria to determine the final payment rate. The PET is designed to provide a reasonable baseline for the service codes coupled with a quantitative methodology to value this additional criteria. For air ambulance service providers, the additional factors that an IDR Entity shall consider include:

  1. Quality and outcomes measurements of the provider that furnished such services.
  2. Acuity of the individual receiving such services or complexity of services
  3. Training, experience, and quality of furnishing medical personnel
  4. Ambulance vehicle type, including the clinical capability level of such vehicle
  5. Population density of the pick-up location.
  6. Demonstration of good faith efforts (or lack thereof) made by the non-participating provider/facility or plan/issuer to enter into in-network agreements

The QPA will not be the provider’s billed or usual or customary charges unless the provider has multiple in-network agreements with those charges. Additionally, up to five claims for similar services within a 30-business day period between the same issuer and provider/facility may be submitted and considered jointly as part of the IDR process.

How the Payer Evaluation Tool (PET) works

ACCT has developed the PET to help providers accurately and transparently describe, account for, and document their capabilities and investments when submitting for reimbursement, developing a bid through the IDR process and defending it with supporting documentation. The PET does so by dividing providers into three graded categories with Level I as the highest clinical and operational capability including specialty teams and aircraft capable of supporting the most complex patients. Most current air medical providers will follow under Level II. See below.

Level III: Ability to provide advanced emergency care comparable to a community hospital emergency department.

Level II: Ability to provide emergency critical or complex care comparable to an advanced ED stabilization or ICU transfer to definitive care.

Level I: Ability to provide highly specialized intensive care comparable to a tertiary ICU.

The tool combines the patient care record with a step-by-step process to appropriately describe and weight baseline and additional factors that Congress included in the law for IDR entities to consider in their final reimbursement decision based on the provider’s level of investment in important areas such as clinical capability, safety, and quality of care while  adjusting for low volume rural and super rural points of patient pick-up and good faith provider efforts to develop in-network agreements. The categories are weighted based on their relative degree of investment and impact on clinical capability, quality, and safety. For example, large, fixed costs such as airplane type are weighted more than variable costs that depend on the patient encounter, such as patient complexity.

At each step the tool will prompt you to compile certain documentation to support how the service meets the selected level. This documentation is critical in the IDR process.

It is also suggested that providers develop a two-page introduction to their program detailing their operations, clinical care, medical oversight, provider qualifications, quality and safety program, aircraft and aviation management, and outside agency accreditation. Using the ACCT Critical Care Transport Standards as a benchmark is highly recommended. This program introduction document can be used in all open negotiations and the IDR process. The program introduction document will then be combined with the documentation of all of the PET steps combined with the HIPAA protected patient care record and any other documentation about the individual patient transport involved in the open negotiation and/or IDR.
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* Balance billing is generally prohibited except in rare scenarios where the patient is stabilized, has the ability to be transported via nonmedical transportation, and consents to out of network charges. Read more on patient notice and consent requirements here.  
** In the case of air ambulance service providers, the geographic region is either all metropolitan statistical areas (MSAs) in a given state, or all of the remaining non-MSA regions in the state. Generally, plans/issuers will calculate rates based on pricing data prior to Jan. 31, 2019 that is trended forward (this avoids payers artificially lowering rates after passage of the law). A plan/issuer is deemed to have sufficient information to calculate the QPA if there are at least three provider contracts for a given service within a given region. If there are not sufficient rates, they move to larger regions and/or a previous year. In cases where there is still insufficient information, they would use a pricing database that has no conflicts of interest.

How Scoring Works

Users will be asked to enter four starting values:

  • The payer-calculated QPA
  • The historic median contracted rate for the payer in question based on provider records
  • The provider’s median in-network rate with all commercial payers
  • The national average historical payment amount ($22,200)*

These starting values will then be adjusted according to a multiplier determined by the provider’s level of investment in six additional criteria cited in the No Surprises Act.

For categories 1-4, performance for the transport will be sorted into one of three clinical capability levels based on the responses selected and supporting documentation provided. Level 1 is the highest possible level of quality, training, and capability possible. Note levels can be different for each category. For example, a program can be a level 1 in terms of quality and outcomes measurements while operating a Level 3 ambulance vehicle type.

Scoring for categories 4, 5, and 6 works a bit differently.

For Category 4 (ambulance vehicle type), in addition to scoring a Level 1, 2, or 3, the tool adds points for the additional investment if the aircraft used to deliver the service was certified by the Federal Aviation Administration under Part 29, which are larger aircraft with more weight capacity which allows for more space for sophisticated clinical equipment to be stored aboard the aircraft as well as more room for medical personnel to actively treat the patient while in flight.

For Category 5 (population density of pick-up location), the tool adds points if point of patient pick-up was considered rural or super-rural according to CMS’ definition in the ambulance fee schedule.

For Category 6 (demonstration of good faith efforts to enter into in-network agreements) the tool adds additional points based on if you can demonstrate affirmative, documented efforts to establish in network agreements and/or ran into concerted efforts on the part of the payer in question to ignore or stymie these efforts.

Upon completion of the survey the PET will calculate adjusted amounts for the four starting values based on the responses provided. Along the way, the user will be prompted to provide supporting documentation that substantiates the responses. These should be used to augment the final report provided by the PET.  Save these documents in a separate electronic file or folder along the way so they are handy for future use.

*The national average historical payment amount is based on 2010 Health Care Cost Institute data which was cited in a 2017 Government Accountability Office analysis (see GAO-17-637). 

Step-by-Step Tips

Step 1: Defining the QPA

The user will be prompted to add four starting values:

  1. The payer-calculated QPA
  2. The historic median contracted rate for the payer in question based on provider records
  3. The provider’s median in-network rate with all payers in the region
  4. The national average historical payment amount ($22,200)*

Step 2: Quality and Outcomes Measures

Maintaining a quality measurement and improvement infrastructure is essential to ensuring a high level of quality of care and clinical outcomes for every patient encounter. The degree of measure complexity is reflective of the level of investment in tracking and analytics capabilities to maintain a superior level of clinical safety, quality, and outcomes.

Question 1) Does flight crew demonstrate a Level 3 capability by having the ability to measure/treat all of the following in flight? Provide documentation for all indicators, e.g., dashboard or scorecard.

  • Serious reportable event
  • Medical equipment failure rate
  • Device dislodgement
  • Transport-related patient injury rate
  • Average STEMI (ST-elevation myocardial infarction) scene time
  • First attempt endotracheal intubation (ETI) success
  • Endotracheal tube (ETT) verification
  • Hemorrhagic shock management
  • Glucose for altered mental status (AMS)

Yes
No

Question 2) Does flight crew demonstrate a Level 2 capability by meeting all Level 3 criteria from the previous question in addition to the following advanced criteria? Provide documentation for all indicators, e.g., dashboard or scorecard.

  • Blood transfusion reactions
  • Ventilator use rates
  • Noninvasive positive-pressure ventilation (NPPV) failure rates
  • End-tidal CO2 monitoring
  • Lung protective strategies

Yes
No

Question 3) Does flight crew demonstrate a Level 1 capability by meeting all Level 3 and Level 2 criteria in addition to the following criteria, demonstrating a superior level of quality and clinical outcomes? Provide documentation for all indicators, e.g., dashboard or scorecard.

  • Unintended neonatal hypothermia
  • Mechanical circulatory support (MCS) mortality rates
  • MCS adverse event rates
  • DASHH 1A- (definitive airway sans hypoxia hypotension 1st attempt)
  • Hypoxic-ischemic encephalopathy (HIE) neonates with target temperature management (TTM)
  • High risk obstetrical (HROB) seizure
  • Hypertension
  • Delivery Rrtes
  • Mechanical circulatory support (MCS) mortality rates
  • MCS adverse event rates
  • Central line
  • Arterial line
  • Umbilical venous catheter (UVC)
  • Umbilical arterial catheter (UVA)
  • Thoracostomy

Yes
No

Question 4) Please compile to include with submission any documentation relevant to measuring the program’s quality and outcomes performance which may include but is not limited to the following:

  • Performance metrics report
  • Written procedure for internal quality measurement and improvement activities

Step 3: Patient Acuity and Service Complexity

Every patient encounter is different. For example, a patient needing rapid transport for a cardiac catheterization requires less sophisticated intervention than a patient on full cardio-pulmonary bypass. As patient acuity and complexity increases, providers must be able to document required investment in increased capability in technical expertise, technology, and interventions that are necessary to meet their needs and save lives.

Question 1) Which of these levels of care most appropriately describes the patient and service in question?

  • Level 3- Advanced Emergency Care Patient has a serious, emergent life and/or limb threatening medical condition involving one organ system requiring close monitoring with ability to reassess and provide care above advanced life support (ALS) care to include cardiac and trauma interventions during flight, that requires air transport.

Examples: Initial cardiac and/or trauma resuscitation; initiation of definitive airways; breathing support; and administration of advanced IV medications beyond the scope of paramedics.

  • Level 2- Emergency Critical Care Patient has a potentially life-threatening, involved, complex and critical medical or traumatic condition involving more than one vital organ system requiring active treatment and resuscitation to stabilize for flight. Patient has a high risk of morbidity without rapid treatment during transport to definitive care.

Examples: Initial resuscitation and stabilization, airway and ventilator management; intubation and airway management; provision, initiation, and management of blood products; chest tube thoracostomy to drain fluid from in/around the lungs; continuous contraction and fetal heart rate monitoring; stroke/cardiac invasive monitoring; cardiac assist devices; and transvenous cardiac pacing.

  • Level 1- Highly Specialized Intensive Care The patient is critically ill or injured with immediate life-threatening condition(s) necessitating the need for active and ongoing resuscitation, external or invasive monitoring, and administration of sophisticated specialized and/or critical care services. Mortality and/or high morbidity would be considered imminent if not for the specialized interventions of the highly trained flight crew before and during transport. The flight is fully equipped with the most up-to-date in-flight technologies, resources, and environment to provide highly intensive and specialized care necessary to stabilize the patient and respond to any status changes in flight and is comparable to an ICU, CCU, or ED setting.

Examples: Multiple system major trauma; ST-elevated myocardial infarction (most deadly form of heart attack); neurologically compromised requiring invasive neurologic monitoring; patients requiring specialized equipment such as a ventricular assist device; prolonged cardiac and respiratory support to those unable to breathe on their own; and high-risk obstetrics where the mother’s or baby’s life is in imminent danger.

Question 2) Please compile any relevant documentation demonstrating the patient acuity and service complexity entailed in the services rendered which are subject to this payment dispute. Relevant documents may include but are not limited to:

  • Copy of extracorporeal cardiopulmonary resuscitation (eCPR)
  • Physician’s statement of medical necessity for air transport
  • Computer aided dispatch (CAD) report and any taped recordings from dispatch lines
  • Emergency Medical Treatment and Labor Act (EMTALA) form (when applicable)
  • Physician notes provided at the site of patient pick-up
  • Results for point-of-care testing or monitoring performed in flight such as ultrasounds and electrocardiograms
  • Copies of referring facility’s medical records (if available)
  • Receiving facility medical records
  • Relevant details from patient’s medical record including any documented comorbidities provided in accordance with HIPAA patient privacy protection

Step 4: Training, Experience, and Quality of Medical Personnel

This element measures and documents investments in maintaining provider clinical skills to effectively respond to myriad and complex situations. Actively maintaining these capabilities requires additional investment in clinician education, ongoing assessments of clinical capability, and medical oversight.

Question 1) Which of the following most appropriately describes the level of training, experience, and quality of the medical personnel that furnished the medical service?

Note: Each level builds on the last so a Level 2 is required to meet all Level 3 criteria in addition to more advanced Level 2 requirements.  

  • Level 3- Ability to provide advanced emergency care comparable to a community hospital emergency department. Two-member crew includes at least one registered nurse (RN) and a paramedic. The lead clinician must have at least three years of clinical experience in conjunction with state licensing requirements. Clinical proficiency is demonstrated through annual didactic training, clinical rotations, or high-fidelity simulation above the ALS scope of care, and oversight by a medical director who is board certified in EMS, emergency medicine or critical care or has completed nationally recognized EMS training, such as NAEMSP’s medical director course. Continuing education includes annual training for skills to include procedure and or cadaver lab with documentation and medical director oversight and sign off.
  • Level 2- Ability to provide emergency critical or complex care comparable to an advanced ED stabilizing care or ICU transfer to definitive care. In addition to meeting all Level 3 requirements above, primary care provider is either an RN, Advanced Practice RN, Physician’s Assistant (PA), or physician and has at least 3 years’ experience in hospital intensive care unit (ICU) or emergency department (ED); (ii) if secondary medical crewmember is an certified flight paramedic (FP-C), has 3 years of ALS experience; or if a respiratory therapist, is a rapid response team (RRT) member with 3 years’ experience; (iii) clinical proficiency is demonstrated via clinical rotations, didactic training, continuing education, quality management, research, medical direction, and sufficient clinical proficiency and competency relevant to the acuity of patients and complexity of services requiring emergency critical care; (iv) medical director is board certified based on program scope of care. At least one member of the team must have two years of transport experience.
  • Level 1- Ability to provide highly specialized intensive care comparable to a tertiary ICU. In addition to meeting all Level 2 and 3 requirements listed above, satisfies the following additional requirements demonstrating a superior level of training, experience, and quality: (i) primary provider has 3 years (4000 hours) in a tertiary hospital ICU/ED or 5 years in a non-tertiary ICU/ED; (ii) clinical proficiency is demonstrated through: a) annual didactic training and clinical rotations; or b) high fidelity simulation relative to highly specialized intensive care scope of care; (iii) medical director is board certified in EMS, emergency medicine or critical care. A documented orientation program provides didactic, clinical rotations, OR rotation for intubation skills, advanced procedure, and cadaver lab to maintain ICU level skills with medical director participation in competency completion and skills check off with annual training with documentation and medical director participation and sign off. The lead clinical team member has advanced specialty certification specific to the population served through a validated exam administered by an independent entity within one year of hire. The program must provide hospital based clinical rotations, continuing education, quality management, research, medical direction, clinical proficiency, and competency relevant to the acuity of patients and complexity of services requiring highly specialized intensive care.

Question 2) Please compile any documentation relevant to the training, experience, and quality of medical personnel who delivered the service(s), which may include but is not limited to:

  • Documentation pertaining to ALL crew member credentials including licensure, years of experience, and completion of a nationally recognized EMS training course or any advance certifications.
  • Documentation of regular clinical skills training including cadaver labs, intubation skills, didactic training, clinical rotations, high fidelity simulations, and annual exams.  Documentation should reflect the frequency of such trainings, note whether medical director review/approval was required, and include the relevant scope of practice as applicable.
  • Documentation pertaining to medical direction and oversight including documented medical direction specific to the services rendered that are under review, completion of a medical director’s course, board certification within the relevant scope of care, oversight of regular skills training by a medical director, and oversight of performance measurement and improvement initiatives by a medical director.

Step 5: Ambulance Vehicle Type and Clinical Capability Level

This element documents provider investment in individual aircraft capability, capacity, and technology to support more robust clinical capabilities and additional safety measures aboard the aircraft. These advancements make a tangible difference in terms of patient care workspace and access, electrical and environmental systems to support advanced medical equipment, and safety technologies including the use of instrument flight which results in a measurable difference in crash worthiness and safety systems, as recognized under Federal Aviation certification requirements.

Question 1) Which of the following most appropriately describes the ambulance vehicle type and clinical capability level?

  • The vehicle contains all necessary equipment to support initial stabilization of trauma and medical patients and can provide advanced emergency care.

Operations limitations are determined by operations specifications (tail and serial number) and visual flight rules (VFR). The aircraft flight environment must maintain and have immediately available basic, advanced life-support supplies and other supplies and equipment necessary to provide advanced emergency care including invasive and non-invasive ventilators, cardiac invasive and non-invasive monitoring equipment as required by the jurisdictional regulatory or licensing authority, all basic and advanced life support interventions including advanced airway management, needle, thoracostomy, intraosseous placement, non-invasive CO2 monitoring, peripheral IV, and waveform capnography. The patient care compartment is of sufficient size to carry and secure all necessary equipment and supplies and accommodate two personnel needed to support the patient care requirements. The aircraft has sufficient onboard electrical power to continuously support all required medical equipment and devices, and sufficient fuel capacity to minimize the need to refuel with a patient onboard.

  • In addition to all above capabilities, vehicle is fully equipped to support the delivery of specialized medical interventions pharmacology and technological life support systems consistent with emergency critical care. Operations limitations are determined by operations specifications (tail and serial number), instrument flight rules (IFR) or VFR with autopilot, and night vision goggles (NVG). The addition of autopilot and night vision goggles provides improved patient safety and service reliability. Aircraft is equipped to handle all age patients and has necessary medical devices and critical care equipment to support emergency critical care clinical capabilities, including invasive monitoring (including hemodynamic, cardiac, and neurological), critical care formulary and medication infusion with multiple IV pumps, rapid sequence induction, administration of a surgical airway, management of a tube thoracotomy and central line, and blood product infusion. Vehicle has the ability to blend medical air for ventilation support and sufficient fuel capacity to reach definitive care without refueling with patient onboard. Medical personnel have free access to patient’s head, chest, abdomen, and pelvis while wearing installed seatbelts. For high-risk obstetrics patients, aircraft has adequate space and patient access for delivery, care of the mother, and care of the infant(s) in the standard loading position. Aircraft is capable of heating and cooling to maintain a temperature range that supports the patient’s clinical needs and an onboard oxygen system with sufficient reserve capacity based on the longest transport and highest flowrate for scope of care and service area.
  • In addition to all above capabilities, the vehicle is fully equipped to support the delivery of specialized medical interventions pharmacology, and technological life support systems consistent with highly specialized intensive care. Operations limitations are determined by operations specifications (tail and serial number), IFR/VFR, tree or more axis autopilot, and NVG. The addition of IFR, three axis autopilot and night vision goggles provide improved patient safety and service reliability for Level I patient acuity and service complexity. Aircraft flight environment, medical equipment and resources are conducive to treat patients using the most recent evidenced-based treatment modalities in flight without limitations in structural or electrical configurations to respond appropriately during flight to any unpredictable patient status changes comparable to an ICU/critical care unit/ED. Aircraft contains and has the ability to support multimodality ventilators appropriate for all ages, extracorporeal oxygenation device, and specialized equipment to support cardiac assist, tube thoracotomy, at least four continuous infusions, placing of endotracheal tubes and central lines, maintaining oxygenation and ventilation for all relevant ages, and point of care testing. Aircraft has the capacity to support (in terms of gross operating weight and electrical capacity) and properly secure highly specialized equipment and at least three medical personnel in addition to the pilot and patient. Medical personnel have access to the patient to deliver care and treatment relative to the pressing medical condition.

Question 1) Was the aircraft that was used to deliver the service certified by the Federal Aviation Administration under Part 29 (i.e. one of the following models)?

    • Airbus- AS365
    • Airbus- BK117
    • Airbus- H145/EC145
    • Airbus- H155/EC155
    • Bell Textron- 222
    • Bell Textron- 412
    • Bell Textron- 430
    • Leonardo- AW139
    • Leonardo- AW169
    • Sikorsky/Lockheed Martin- S-76

Yes
No

Question 3) Please compile any supporting documentation relevant to ambulance vehicle type and clinical capability level including but not limited to:

      • Certification under Part 29
      • Documentation of relevant, advanced clinical or flight capabilities and equipment onboard aircraft
      • Aircraft specifications including weight, personnel, fuel, and electric capacity and ability to secure highly specialized medical equipment
      • Documentation of pilot credentials, training, and experience to demonstrate aviation capability
      • Documentation pertaining to crash worthiness and attenuation

Step 6: Population Density of Pick-up Location

The NSA specifically recognizes the need to account for the additional challenges air ambulance providers face in rural areas to maintain service, including purchasing and maintaining aircraft with increased range performance coupled with lower service volumes. This element is designed to recognize the high fixed costs required to maintain patient access to air ambulance services in rural areas. Accordingly, they are worth a relatively high point value but are available to only a small subset of air ambulance providers operating in rural or super rural areas.

Question 1) Which of the following describes the pick-up area (as defined by the ambulance fee schedule)? Look up here.

    • Urban area
    • Rural area
    • “Super-rural” area

Question 2) Please upload any relevant documentation pertaining to the patient pick-up location including zip code and/or demonstrated CMS classification of rural or super rural status.

Step 7: Demonstration of Good Faith Efforts

This category documents provider commitment to reach in-network status or negotiate single case agreements for the claims under dispute, payer responsiveness to these efforts, and the provider’s willingness to reach in-network status with other local carriers more generally. Taken together, this information is intended to demonstrate the level of effort to reach in-network agreements made on behalf of both parties.

Question 1) Does the program have documented proof of good faith efforts made as a facility/provider to reach in-network agreements with the payer in question, and/or efforts by the payer to effectively block or ignore those efforts? Please select all that apply. Please indicate relevant timeframes or dates.

  • Documented efforts to reach in-network or single case agreement on claim(s) under review
  • Prior settlement of a single case negotiated agreement between two parties
  • Documented evidence of payer unwillingness to respond to or reach an in-network or single case agreement for the claim(s) in dispute
  • Payer withholding of claims in dispute for leverage to force a lower settlement
  • Payer issued payment directly to patients for claims under dispute
  • Other
  • None to report

Question 2) Please compile any documentation that substantiates any of the claims made in the previous question pertaining to good faith efforts to enter into in-network contracts. Please also  compile any documentation that demonstrates efforts to reach in-network status with other payers in the program’s local region.

Step 8: Your Results

The Payer Evaluation Tool takes all of this information, weights it, and converts it into a final multiplier that can be less than, greater than, or equal to a value of 1, which is then multiplied by the four starting values to provide four distinct adjusted end values to use in negotiations with payers and IDR entities.

For technical or logistical questions about the tool, please contact Chuck Walker at [email protected].

For content related questions about the QPA and dispute resolution process, please contact Roxanne Peek at [email protected].