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Federal No Surprises Act information for providers

Find information about Federal No Surprise bills and the provider negotiation and independent dispute resolution process.

How does the Federal No Surprises Act protect consumers?

How does the Federal No Surprises Act protect consumers?

When a member receives emergency care — or is treated by an out-of-network provider at an in-network hospital, ambulatory surgical center or by an air ambulance provider — they are protected from balance billing (meaning, a surprise bill for the amount over the amount the plan paid).

 

The Federal No Surprises Act (NSA) requires the member’s cost share to be based on the Qualifying Payment Amount (the QPA) — otherwise known as the Median in-network rate. Providers cannot bill the member for more than their cost share.

Important information for providers

The Federal No Surprises Act (NSA) regulation was effective with service dates on or after January 1, 2022.  The regulations apply to plan years (in the individual market, policy years) beginning on or after January 1, 2022 for fully insured plans and to contract years beginning on or after January 1, 2022 for self-funded plans.  The regulations do not apply to:

 

  • Medicare Advantage plans
  • Plans not subject to U.S. law
  • Retiree-only plans
  • State Medicaid plans

To easily determine if the Federal NSA applied to a specific claim, refer to your Explanation of Benefits (EOB) which provides the NSA disclosures and explains how to determine the Qualified Payment Amount (QPA). The QPA is calculated by subtracting the “not payable” amount from the “submitted charges” amount shown on each covered service line on the EOB. The QPA was developed in accordance with the requirements defined in the NSA. The member’s cost share was calculated based on the QPA. As a reminder, the member is only responsible for the cost share reflected on the EOB and you are prohibited from balance billing the member for any other amount for covered services.

Under the NSA, if you don’t accept our calculated QPA, you can initiate an Open Negotiation within 30 business days from receipt of your EOB. To open a negotiation:

 

If you need assistance to initiate an Open Negotiation, call our Provider Contact Center team at 1-888-632-3862 (1-888-MD AETNA) (TTY: 711).

If we do not reach a settlement agreement during the Open Negotiation period, you may initiate the Federal Independent Dispute Resolution (IDR) process for eligible NSA claims.  You have 4 business days beginning on the 31st business day following the conclusion of the Open Negotiation period to file for IDR. To initiate IDR:

 

Legal notices

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna).

This material is for information only. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information is believed to be accurate as of the production date; however, it is subject to change.

Health benefits and health insurance plans contain exclusions and limitations.