No Surprises Act of 2021: Out of Network Payment Disputes

The No Surprises Act of 2021 provides federal protections for patients against surprise billing and balance billing for certain services. Out-of-network providers are generally prohibited from balance billing members for the following services:

• Out-of-network emergency care
• Certain non-emergent services by out-of-network providers during visits to in-network facilities
• Out-of-network air ambulance services

Visit CMS’ website for more information.

Open Negotiation Process

Out-of-network claims that qualify for No Surprises Act protections are priced by Point32Health at the Qualifying Payment Amount (QPA). Out-of-network providers who disagree with the QPA may initiate an open negotiation within 30-business-days of receipt of the initial payment or notice of denial of payment. You may initiate an open negotiation by contacting the delegate specified on your explanation of payment or as specified below, as we utilize several delegates for pricing out-of-network claims.

If you have questions, please reach out to the appropriate delegates listed below. or refer to the open negotiation process request form.

Independent Dispute Resolution

If an agreement cannot be reached through the 30 business day open negotiation process, the out-of-network provider may request an Independent Dispute Resolution (IDR) through the CMS website within 4 business days after the end of the open negotiation period.

When initiating a dispute on the CMS website, please use the below contact information to ensure your request is routed to the correct delegate: