This article is for acute care hospitals, ambulatory surgical centers, and out-of-network providers caring for our members
The No Surprises Act, enacted as part of the Consolidated Appropriations Act (CAA) in late 2020, provides new federal consumer protections against balance billing for medical bills under certain circumstances. Claims subject to balance billing protections may occur:
Ground ambulance claims are not included under the No Surprises Act.
We want to let you know how we’re educating our members about their rights and protections under the law. We are posting disclosures explaining the rights and protections our members have under the law to our public website in late December: https://www.bluecrossma.org/disclaimer/member-rights. Our Explanation of Benefits (EOB) when we pay bills covered by the law will direct members to the following explanation of the law:
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
Under the No Surprises Act, non-participating providers are prohibited from balance billing under the circumstances described above.
The statute requires providers, including hospitals, to make notice about balance billing requirements and prohibitions publicly available and provide them to consumers. The regulations supporting the No Surprises Act detail information that must be included in such notice.
The federal law also includes provisions allowing providers to request negotiation of the payor’s payment for bills subject to the No Surprises Act, and if negotiation fails, to enter into the Independent Dispute Resolution (IDR) process, also known as arbitration, to determine the allowed payment amount.
|Mail:||Blue Cross Blue Shield of MA
PO Box 986065
Boston, MA 02298
|Phone:|| 1-800-882-2060 (physicians)
1-800-451-8124 (ancillary providers)
The request should include both the Open Negotiation Notice and the Request for Claim Review forms.