No Surprises Act: What Providers Need to Know

The No Surprises Act, as part of the Consolidated Appropriations Act (CAA), has been effective with dates of service on and after January 1, 2022, and provides greater consumer protections to patients by addressing surprise medical bills at the federal level.

The No Surprises Act required health plans to implement changes that impact both members and providers. Some of these changes will affect providers both in and out of Ambetter’s network, including:

Elimination of balance billing
Open negotiation process for out-of-network providers
Expansion of provider directory requirements
Expansion of continuity of care protections

Additional provider resources about the No Surprises Act can be found on the Centers for Medicare and Medicaid (CMS)’s website.

To submit an open negotiation request for a paid or denied service eligible under the Federal No Surprises Act, please complete the request form (PDF) and email to AmbetterFederalIDRandOpenNegotiationRequests@centene.com and one of our negotiators will contact you.

Balance Billing

A cornerstone piece of the federal No Surprises Act is that it prohibits providers from balance billing patients when certain out-of-network care is received. This applies to the following service types:

Air ambulance services
Emergency services
Emergency post-stabilization services
Emergency services rendered to our member from another state; and
Out-of-network non-emergency services at an in-network hospital, a hospital outpatient department, a critical access hospital (as defined in section 1861 (mm)(1) of the Social Security Act), or an ambulatory surgical center (as described in section 1833(i)(1)(A) or the Social Security Act).

What This Means for Providers

Out-of-network providers should not bill Ambetter members for covered services for any amount greater than their applicable in-network cost sharing responsibilities when:

Members receive a covered emergency or air ambulance service from an out-of-network provider. This includes services members may get after they are in stable condition, unless the out-of-network provider obtains the member’s written consent.
Members receive non-emergency ancillary services (emergency medicine, anesthesiology, pathology, radiology, and neonatology, as well as diagnostic services (including radiology and laboratory services) from an out-of-network provider at an in-network hospital or in-network ambulatory surgical facility.
Members receive other non-emergency services from an out-of-network provider at an in-network hospital or in-network ambulatory surgical facility, unless the out-of-network provider obtains the member’s written consent.

For Services Covered by The No Surprises Act

If you are an out-of-network provider, the allowed amount is based on the recognized amount using the methodology outlined in the interim final rules of the Consolidated Appropriations Act (i.e., lesser of billed charges and the Qualifying Payment Amount). For emergency services, emergency post stabilization, and non-emergency services, the member’s cost share is calculated against the recognized amount, and for air ambulance services, the member cost share is calculated against the lesser of the Qualifying Payment Amount or the billed amount.

Understanding Payment

Evidence of Payment Remark Codes:

EX cc – Pay: Priced According to Qualified Payment Amount
Pricing Rules

EX ck – Pay: Qualified Payment Amount Manually Overridden

Claim Adjustment Reason Codes:

Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability)

Remittance Advice Remark Codes

N860	Alert: The Federal No Surprise Billing Act Qualified Payment Amount (QPA) was used to calculate the member cost share(s).
N859	Alert: The Federal No Surprise Billing Act was applied to the processing of this claim. Payment amounts are eligible for dispute pursuant to any Federal documented appeal/ grievance/ dispute resolution process(es).

Should you disagree with the payment amount, you may have the right to initiate a 30-business-day open negotiation period. Any such request must be initiated within 30 business days from the date of the Explanation of Payment (EOP). The negotiation period is for purposes of determining the out-of-network rate for covered services.

In some states, Federal and State processes may be available to you.

Open Negotiation Request

The No Surprises Act provides a federal independent dispute resolution (Federal IDR) process that group health plans, health insurance issuers of group and individual health insurance coverage, and FEHB carriers and out-of-network or non-participating health care providers, facilities, and providers of air ambulance services may utilize to determine the out-of-network rate for certain services following the end of an open negotiation period.

The Federal IDR process is available only for certain services, such as out-of-network emergency services, certain services provided by out-of-network providers at an in-network facility, or out-of-network air ambulance services. The Federal IDR process is also only available if a state All-Payer Model Agreement or specified state law does not apply.

What is an Open Negotiation Period?

The open negotiation period is a period of up to 30 business days to determine an agreed-upon amount for the total out-of-network rate (including any cost sharing) for an item or service furnished by a non-participating provider, non-participating facility, or a non-participating provider of air ambulance services to a participant, beneficiary, or enrollee in a group health plan, group or individual health insurance policy, or FEHB carrier and for which a payment is required to be made by the plan or coverage.

Request for Open Negotiation Form (PDF)

Independent Dispute Resolution

If the federal independent dispute resolution process is available to you and the out-of-network rate is not mutually agreed to during the open negotiation period, you have the right to initiate the Independent Dispute Resolution process within 4 business days after the end of the open negotiation period. Please refer to the following when completing the IDR submission:

Name: Ambetter
Mailing Address: PO Box 10407, Van Nuys, CA 91410
Email: AmbetterFederalIDRandOpenNegotiationRequests@centene.com

Provider Directory

The No Surprises Act includes new requirements regarding provider directory information. These requirements apply to commercial individual market issuers and group health plans.

Provider Expectations

Each healthcare provider/facility must have in place business processes to ensure timely provision of provider directory information to individual commercial market issuers and group health plans. In addition to existing requirements, providers must submit provider directory information to a plan or issuer when either of the following conditions is met:

When the provider or facility terminates a network agreement; or
When there are material changes to the content of provider directory information.

Compliance with these requirements ensures that provider listings remain visible to members in provider directories. Providers should work internally to confirm that the directory information they verify is correct and compliant with industry standards.

Health Plan Actions

In support of the No Surprises Act (section 116), Ambetter will:

Capture providers’ digital contact information (i.e., web addresses or email addresses) for display in online and print directories.
Verify the provider directory data (i.e., name, address, specialty, telephone number and digital contact information) every 90 days
Ambetter will remove providers from the directory whose provider data is not verified by the provider within 180 days of the last verification.
Update key demographic information within two business days of submission from contracted providers.

To meet these requirements Ambetter has partnered with a third party vendor for the No Surprises Act requirements for provider directories. The contracted vendor service will perform a quarterly cleansing of the Ambetter directory information and regular clean up of the directories will be performed by Ambetter Health Plans.

Continuity Of Care

There may be cases where a member is receiving care from a network provider that subsequently becomes an out-of-network provider relative to the member’s plan. In those instances, members undergoing continuous care for certain conditions may continue to receive services at the network level of benefits from that now out-of-network provider for a period of up to 90 days or until the treatment is concluded, whichever is sooner.

If the patient chooses to continue with their current provider during the continuity of care period, the provider is required to accept the previous in-network payment and cost-sharing amounts and continue to meet all previously applicable terms and conditions.

The No Surprises Act defines continuing care patients as those who, with respect to the provider:

Have an acute illness serious enough to require specialized medical treatment to avoid death or permanent harm
Have a chronic illness that is life-threatening, degenerative, potentially disabling, or congenital, and requires specialized care
Are receiving institutional or inpatient care
Are scheduled to undergo non-elective surgery, including postoperative care
Are pregnant and undergoing treatment for pregnancy
Are/were determined to be terminally ill and are receiving treatment for such illness