The
federal No Surprises Act of 2021 received rulemaking restricts certain out-of-pocket costs to commercial consumers resulting from surprise billing and balance billing. This rule goes is in effect for plan, policy, or contract years starting on or after January 1, 2022, for group health plans, health insurance issuers and Federal Employees Health Benefits (FEHB) program carriers and serves to:
- Ban balance billing for emergency services, air ambulance, and certain professional services provided by an out-of-network provider at an in-network facility. Cost-sharing for these services must be determined on an in-network basis.
- Requires that patient cost-sharing (copayments, co-insurance, or a deductibles) for the services outlined above cannot be higher than if such services were provided by an in-network provider. Any cost-sharing obligation must be based on median in-network provider rates.
- Prohibits balance billing for qualifying items or services provided by an out-of-network provider at an in-network facility unless a patient provides consent via the process required by CMS. You can reference CMS information here. Providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill the patient more than in-network cost-sharing rates.
The forms and information below are provided in accordance with the federal No Surprises Act of 2021.
Open Negotiation Process
Non-participating providers who render services in an emergency room, an air ambulance, or for certain non-participating providers (for example, an anesthesiologist or radiologist) that provide non-emergency care in an participating facility will receive a Qualified Payment Amount (QPA) when the claim pays the first time.
If a non-participating provider rejects the QPA, they can engage in a 30-business-day open negotiation period with our designee, Clear Health Strategies, to agree on the appropriate rate for applicable items or services. You can find
more information from Clear Health Strategies here.
As a reference for the open negotiation process with Clear Health Strategies, you can review the CMS documentation
here.
Independent Dispute Resolution
If the Open Negotiation Process fails, either party can elect the Independent Dispute Resolution (IDR) process during the 4-business-day period beginning on the 31
st business day after the start of the open negotiation period. You can learn more about initiating the IDR process, view a sample Notice of IDR Initiation, and access the necessary IDR initiation form
here.
Both parties must agree on the Independent Dispute Resolution entity. Failure to agree will result in an entity chosen by CMS (Centers for Medicare and Medicaid). Upon selection of the Independent Review entity, both parties will submit offers for payment as well as supporting documentation. The selected Independent Review Entity will issue a binding determination on the payment which will be considered final.
In the case of extenuating circumstances, either party may request an extension of the IDR time period by filling out
this form and submitting it to CMS.