January 12, 2023
The No Surprises Act, part of the Consolidated Appropriations Act 2021 (CAA), creates new protections against out-of-network balance billing and sets up a new process called Independent Dispute Resolution (IDR), which providers (including air ambulance providers), facilities, and health plans can use to resolve payment disputes for certain out-of-network charges.
When a provider or facility gets a payment denial notice or an initial payment from a health plan for certain out-of-network services, the health plan, provider, or facility can initiate an open negotiation period that lasts 30 business days. At the end of the negotiation period, if the health plan and provider or facility haven’t agreed on a payment amount, either party can begin the Federal Independent Dispute Resolution process.
These rules went into effect for plan years beginning on or after January 1, 2022. Since then, Premera has covered the arbitration fees for self-funded and OptiFlex business because the official rule was released too late in 2021 to update contracts with the necessary language. Beginning March 1, 2023, we will start passing arbitration fees and associated administrative costs prospectively beginning March 1, 2023, for self-funded and OptiFlex groups that renewed in January, February, or March, and as groups renew with April – December effective dates.
The fees will be billed based on the incurred date and appear on the monthly claims invoice. This change doesn’t include any added claims payments required as the result of arbitration; those amounts have been passed to self-funded and OptiFlex groups through claims costs since the IDR process was implemented.
Please contact your account manager with any questions.