Surprise Billing Provisions of No Surprises Act

The No Surprises Act (NSA) is a requirement of the Consolidated Appropriations Act (CAA) of 2021. Illinois House Bill 4703 (Illinois Public Act 102-0901) reinforces provisions of the federal NSA on a state level and sets an Illinois-specific dispute process for out-of-network providers.

Member Protections Against Surprise Billing

NSA

Under NSA, most out-of-network providers are no longer allowed to balance bill patients for:

  • Emergency services
  • Out-of-network care during a visit to an in-network facility
  • Out-of-network air ambulance services if patient’s benefit plan covers in-network air ambulance services

Illinois

Under Illinois law, out-of-network providers are also not allowed to balance bill patients for:

  • Covered services resulting from an unforeseen, urgent medical need that occurs during the delivery of other medical services.

Negotiation and Dispute Resolution

NSA

For items and services subject to NSA requirements, member cost-share will be calculated based on the lesser of a qualified payment amount or the provider’s billed charge. The qualified payment amount is the median contract rate calculation set forth by the NSA and related interim rules.

Generally, if a non-participating provider isn’t satisfied with a payment on items or services subject to NSA, they can first initiate a negotiation with the plan and, if the negotiation fails, can pursue binding independent dispute resolution (IDR). Through this process, the parties submit their respective offers and other required information to their designated arbitrator, and the IDR entity will issue a written decision that will determine whether any additional amount will be paid to the provider.

The NSA and related interim rules state that some of its provisions such as member cost-share requirements, claim payment deadlines and availability of the federal IDR process, do not apply if a state law provides a method for determining the total amount payable to the provider for that item or service.

Illinois

Under Illinois law:

  • The time period to settle before arbitration is 30 calendar days.
  • A final offer from the plan and response from the provider are required before proceeding to arbitration.
  • Arbitration requests must be submitted to the Illinois Department of Insurance (IDOI).
  • Arbitration filing must be done through the electronic filing system of the American Health Law Association or American Arbitration Association, with a copy sent to IDOI.
  • Arbitrator decisions must be reached within 45 days.

Non-Participating Providers: How to Request a Claim Review and Initiate a Negotiation

Claims for the following services may be eligible for payment review under NSA and Illinois law if you don’t have a contract with us:

  • Emergency services or stabilization for an emergency
  • Covered services resulting from an unforeseen, urgent medical need that occurs during the delivery of other medical services
  • Services provided by non-participating providers at a contracted facility
  • Air ambulance services

To initiate the process:

  • Log on to Availity® Essentials to initiate a negotiation for eligible services. Eligible services will also be noted on your provider claim summary.
  • If you want to dispute the payment amount, you may open negotiations through Availity.
  • For additional details, refer to the IDR user guide.

Only registered Availity users can access the IDR portal. If you aren’t registered, go to Availity and select “Register” to complete the guided online process, at no cost.

Emergency Services

NSA

CAA expands the current definition of emergency services. Emergency services continue to be defined by the prudent layperson standard. If a plan covers services in an emergency department or independent freestanding emergency room, the following services will be included as emergency services under NSA:

  • Screening and ancillary services necessary to evaluate the emergency condition (participating and non-participating)
  • Services to stabilize the patient (participating and non-participating)
  • Post-stabilization outpatient observation or an inpatient or outpatient stay, if the plan would cover the services (non-participating only)

NSA and Illinois 

Under NSA and Illinois law, the types of facilities that can provide ancillary services are:

  • Hospitals
  • Outpatient hospitals
  • Critical access hospitals
  • Ambulatory surgical centers
  • Other facilities licensed under the Hospital Licensing Act 

To Learn More

 

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