No Surprises Act

Frequently asked questions

What is the No Surprises Act?

The No Surprises Act provides patients with protection from surprise medical bills under certain circumstances. It also mandates transparency regarding healthcare costs and holds patients liable for in-network cost-sharing amounts only.

Additionally, the legislation allows healthcare providers and insurers to negotiate reimbursement separately while insulating the patient from that process. It also includes a provision for an independent dispute resolution process if necessary. The Departments of Health and Human Services (HHS), Treasury, and Labor are tasked with issuing regulations and guidance to implement the No Surprises Act, most of which is set to go into effect on January 1, 2022.

Starting January 1, 2022, it will be illegal for providers to bill patients for more than the in-network cost-sharing price if the patient did not choose or know that the service would come from an out-of-network provider.

In addition, certain nonemergency out-of-network ancillary services may not be billed beyond their in-network cost-sharing amount regardless of whether the patient received notice or consented to the service. This includes the following items and services: emergency, anesthesiology, pathology, radiology, and neonatology services.

Nor can an out-of-network provider use the notice and consent process if there is no in-network provider available to furnish the item or service at the facility. The HHS secretary has the discretion to add or remove items and services through the rulemaking process.

What is the independent dispute resolution (IDR) process?

If the provider is unable to agree on a payment amount, the No Surprises Act offers an IDR process to determine the amount.

Providers and payers have the option to begin a 30-day “open negotiation,” during which the provider and the payer can negotiate on a mutually agreeable payment amount. The open negotiation period may be initiated by any party during the 30-business-day period beginning on the day the nonparticipating provider, facility, or nonparticipating provider of air ambulance services receives either an initial payment or a notice of denial of payment for an item or service.

If the IDR process is triggered, an external IDR entity (arbiter) will be assigned to decide what amount the provider must accept as final payment — either the amount offered by the plan or the amount requested by the provider.

If the parties have not reached an agreed-upon amount for the out-of-network rate during the 30-day open negotiation period, either party may initiate the Federal IDR process within four-business-days.

Can providers opt out of this mandate?

No.

What is the qualifying payment amount (QPA)?

Under the No Surprises Act, insurers calculate median contracted rates in the local market, called QPAs, in order to establish a basis for out-of-network provider payments and member cost-sharing amounts for each item and service for which the act applies. Under the No Surprises Act regulations, the QPA is the presumptive payment rate in the IDR process.

What form should be used to obtain consent?

A fully completed Standard Notice and Consent Documents Under the No Surprises Act developed by The Department of Health and Human Services (HHS) is the only form we may accept.

How do I submit a consent form?

For electronically submitted claims, the consent form needs to be sent to Capital Blue Cross via fax to 717.541.3702 or 866.682.2242, the ANSI 837 claim must contain a PWK segment to indicate the consent form is being faxed. The PWK segment is in the 2300 loop, and the PWK01 should be CK. Providers may need to work with their vendor/clearinghouse to ensure this information is transmitted to Capital.

For Direct Data Entry via Availity, the consent form should be attached to the claim, using Attachment Support Data for Claim1.

For Paper claims, send the consent form with the claim form.

1Support Data for Claim, will send a PWK01 of OZ. The other option that is available in Availity is Certification which will send a PWK01 of CT.

What information must be submitted on the claim?

Claims using the CMS1500, Professional Claim format, must include the Service Location. In the ANSI 837 Professional Claim format, this is submitted in the 2310C loop, with a NM101 qualifier of 77.

For paper claims, this is submitted in Field Locator 32.

Why did my claim deny?

If your claim denies for missing information, claim could be missing the Service Facility and/or the consent form has not been received but you submitted a PWK01 of CK.

How do I initiate open negotiations or the independent dispute resolution (IDR) process?

The open negotiation request form can be found on our out-of-area/network provider resources page beginning January 1, 2022.

The open negotiation request form should only be used for the 30-day open negotiation period and is not intended for original claim submissions, claim adjustments, or claim corrections. Please submit only one (1) form per request. Negotiation requests should be sent to:

Capital Blue Cross

The IDR initiation form can be found on our out-of-area/network provider resources page beginning January 1, 2022.

The IDR initiation form form should only be used for the Federal IDR process and is not intended for original claim submissions, claim adjustments, or claim corrections. Please submit only one (1) form per request. Negotiation requests should be sent to:

  1. The initiating party must furnish the Notice of IDR Initiation to the Departments by submitting the notice using the Federal IDR portal. The initiation date of the Federal IDR process will be the date of receipt of the Notice of IDR Initiation by the Departments.
  2. Capital Blue Cross

What other information should I include with my open negotiation/IDR requests?

To help expedite the open negotiation process, you should submit the additional key elements:

  • Claim number
  • Provider first and last name (professional providers)
  • Provider group name (professional providers)
  • Facility name (facility providers)
  • Provider national provider identifier (NPI)
  • Plan name
  • Member first and last name

Why did I receive an SOR for a denied claim? I am a non-par provider and have not received these from Capital in the past.

Capital must issue payments as well as notice of denials directly to nonparticipating providers for claims that meet the conditions of the No Surprises Act. Some claims that meet those conditions may deny for other reasons (duplicate claims, missing information), the nonparticipating providers would still receive a notice for those claims.