No Surprises Act
Frequently asked questions
What is the No Surprises Act and when does it apply?
The No Surprises Act (“Act”) protects patients from unexpected medical bills under certain circumstances when they receive care from an out-of-network provider and were unable to choose an in-network provider. The Act applies to emergency services, out-of-network specialists at in-network facilities and air ambulance services. The Act also prohibits providers from balance billing patients and requires plans to pay providers directly, rather than through member reimbursement.
The Act allows providers and payers to negotiate reimbursement separately while insulating the patient from that process. It establishes an independent dispute resolution (IDR) process for providers and plans to resolve pricing disputes when negotiations fail. The Departments of Health and Human Services (HHS), Treasury, and Labor are tasked with issuing regulations and guidance to implement the No Surprises Act, and have issued interim final rules in two parts IFR I and IFR II.
Starting January 1, 2022, providers are prohibited from “balance billing” patients for more than the in-network cost-sharing amount, when the out-of-network services qualify for protection under the Act.
While patients can provide consent to balance billing in limited circumstances - after receiving notice of their rights - some services are not eligible for patient consent. This includes items and services for: emergency, anesthesiology, pathology, radiology, and neonatology. HHS has the discretion to amend this list through future rulemaking.
Patients are also not eligible to provide consent to balance billing if there is no in-network provider available to furnish the item or service at the facility.
What is the independent dispute resolution (IDR) process?
The Act establishes a new arbitration system (IDR) to resolve disputes over payment amounts between a plan or issuer and out-of-network providers. IDR is only available for disputes involving out-of-network claims that are within the scope of the Act (emergency, specialist at an in-network facility and air ambulance). In addition to issuing IDR II to set forth the details of IDR, the federal agencies issued an FAQ regarding IDR on February 10, 2022.
Before providers can open an IDR case, they must first initiate a mandatory 30-day “open negotiation,” during which the provider and the payer can negotiate an agreeable payment amount. The open negotiation period may be initiated within 30 business days after the provider receives initial payment or notice of denial of payment for an item or service.
If the open negotiation period expires without agreement and IDR is timely initiated, an external IDR entity will be assigned to determine the payment amount. Under IFR II, the IDR entity will choose between the amount offered by the plan or the amount requested by the provider. The amount submitted to the IDR entity that is closest to the QPA is the presumptive payment amount under IFR II.
Can providers opt out of this mandate?
No. The requirements of the Act apply to all claims falling within its scope and must be followed by payers and providers.
What is the qualifying payment amount (QPA)?
The QPA is a payer’s median network rate in the local geographic region for items and services subject to the Act’s requirements. The QPA can be used to determine an appropriate claim payment to providers and must be used to determine member cost-share amounts. In IDR, the presumptive choice for the IDR entity to select is the payment amount closest to the QPA for the item of service.
What form should be used to obtain consent?
Standard Notice and Consent Documents Under the No Surprises Act and published 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.
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
- Email: Capital CAA Negotiation IDR
- Fax number: 717.541.6915
- Mail: AGR Dept.- Provider Unit
PO Box 779518
Harrisburg, PA 17177-9518
The IDR initiation form can be found on our out-of-area/network provider resources page.
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:
- 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.
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.