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 members for the following:
Visit CMS’ website for more information.
Out-of-network claims that qualify for No Surprises Act protections are priced by Point32Health at the Qualifying Payment Amount (QPA). Out-of-network providers who disagree with the QPA may initiate an open negotiation within 30 business days of receipt of the initial payment or notice of denial of payment. You may initiate an open negotiation by contacting the delegate specified on your explanation of payment or as specified below, as we utilize several delegates for pricing out-of-network claims.
If you have questions, please reach out to the appropriate delegates listed below or refer to the open negotiation process request form.
If an agreement cannot be reached through the 30 business day open negotiation process, the out-of-network provider may request an Independent Dispute Resolution (IDR) through the Centers for Medicare and Medicaid Services (CMS) website within four business days after the end of the open negotiation period.
When initiating a dispute on the CMS website, please use the below contact information to ensure your request is routed to the correct delegate:
As an alternative to the federally administered IDR process, New Hampshire providers can utilize the state’s new dispute resolution process for dates of service beginning Jan. 1, 2025. Prior to initiating the open negotiation, providers must decide whether to use the federal process or the state’s IDR process. Providers who choose the state’s IDR process must follow the steps and utilize the forms available on the New Hampshire Insurance Department’s website.