No Surprises Act of 2021: Out-of-Network Payment Disputes

Ending Surprise Medical Bills

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 Commercial 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 Harvard Pilgrim at the Qualified Payment Amount (QPA). Out-of-network providers who disagree with the QPA may initiate a 30-business-day open negotiation process by contacting the delegate specified on your explanation of payment. We utilize several delegates for pricing out-of-network claims, including:

Zelis:

ClearHealth Strategies

Harvard Pilgrim Health Care

For more information, refer to the open negotiation process request form

Independent Dispute Resolution

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