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Providers

Federal No Surprises Act

Find out how the No Surprises Act protects patients from balance billing and how to dispute a qualifying payment amount.

The No Surprises Act protects patients from balance billing

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.

Dispute a qualifying payment amount

Providers can initiate the open negotiation process by completing the Qualifying Payment Amount (QPA) Dispute Form.

Fill Out QPA Dispute Form

Other ways to initiate open negotiation

You can initiate an open negotiation by email or mail.

  1. Visit the US Department of Labor No Surprises Act webpage
  2. Click the "Open Negotiation Period Notice" link
  3. Download and complete the template
  4. Submit to Blue Cross NC 
    by email: QPA@bcbsnc.com

    or by mail:

    Network Management - Surprise Billing
    PO Box 2291
    Durham, NC 27707

If you need additional assistance, please call 888-302-0530.

More information

The No Surprises Act now holds members harmless from surprise bills when receiving:  

  • OON emergency services:  
    • OON emergency room visits  
    • OON inpatient admissions from the emergency room  
    • OON observations admissions from the emergency room  
  • OON air ambulance services 
  • Services from OON hospital-based providers at INN facilities, such as Anesthesia, Radiology, etc. 

  • Date of service prior to January 1, 2022
  • Medicare Advantage plans
  • Plans not subject to U.S. law
  • Retiree-only plans
  • State Medicaid plans

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.

Email QPA@bcbsnc.com to learn more about the QPA Methodology.

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:

  • Requests for an appeal following a voluntary notification review Observation recommendation. This is not an adverse benefit determination and is only a recommendation at this specific stage.
  • Requests for an appeal related to QPA pricing. Providers must initiate the open negotiation process.