In balance billing, an out-of-network provider charges for the leftover amount after the health plan pays its share. An unexpected balance bill is called a surprise bill.
Providers can initiate the open negotiation process by completing the Qualifying Payment Amount (QPA) Dispute Form.
The No Surprises Act now holds members harmless from surprise bills when receiving:
On the first page of your EOP there is a remarks box that lists codes. Code X00 means “This claim is subject to Surprise Billing Legislation Protections.” Additional disclosure information is provided. Throughout the following pages, if the ‘Remark Code’ column states X00, it is a Surprise Billing claim.
The QPA is listed in the Contracted Charges column of your EOP.
If we cannot come to an agreement after 30 business days, you may pursue the independent dispute resolution (IDR) process designed by the Centers for Medicare & Medicaid Services (CMS) as outlined in the No Surprises Act and regulations pursuant to the Act.
The appeals team will follow their normal appeals process. However, appeals will not review the following in terms of Surprise Billing:
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