Eligibility overview

Introduction

The No Surprises Act (NSA), effective January 1, 2022, provides billing protections to patients when receiving emergency care, non-emergency care from out-of-network (OON) providers, and air ambulance services from OON providers.

The NSA established the Independent Dispute Resolution process as a mechanism for providers and payors to determine the appropriate OON payment rate for items and services subject to the surprise billing protections in the NSA.

Maximus serves as an Independent Dispute Resolution Entity to resolve disputes between the OON provider and the health insurance plan.

Criteria for eligibility

For Maximus to render a payment determination for a dispute, the dispute must follow specific eligibility guidelines set forth in the NSA.

The items or services in dispute must fall into the three main categories specified in the NSA to be eligible for the IDR process:

• Covered emergency services by an out-of-network provider/facility.
• Covered non-emergency services from an out-of-network provider delivered as part of a patient’s visit to an in-network facility.
• Covered services from out-of-network providers of air ambulance services.

Item/services in dispute must have been furnished after the NSA being enacted on January 1, 2022

Timeframes, steps, and guidelines for eligibility

Additionally, the IDR process requires certain timeframes, required steps, and specific guidelines for all item/services in dispute to be eligible for the IDR process:

• Open Negotiation: All parties must go through a 30-business day open negotiation period prior to starting the Federal IDR process.
• Notice of IDR Initiation: The initiating party must submit the required forms to start the Federal IDR process within 4 business days after the end of the 30-business day open negotiation period.
• Specified State Law or All Payer Model Agreement: In some states, the Federal IDR process is surpassed by Specified State Law or All-Payer Model Agreement that provides a method for determining the total OON amount payable. Learn more about determining the applicability of the Federal IDR Process here Basic State - Territory IDR Deeming Chart
• Non-eligible circumstances: The NSA protections do not apply to the following:
  • Certain governments programs such as Medicare, Medicaid, Indian Health service, Veterans Affairs Health Care, Tricare
  • Not covered item/services under the health plan
  • Ground ambulance services
  • Certain types of health plans such as short-term plans, retiree-only, worker’s compensation plans, etc.

Facilitate your review

To facilitate your eligibility review, please include all important documentation such as:

• Complete Explanation of Benefits letters
• Proof of submission of forms with dates and recipients including: Proof of initiating open negotiation (including email or screenshot of email reflecting that the Open Negotiation Notice was sent to the non-initiating party) and Proof of Independent Dispute Resolution initiation (including email or screenshot of email reflecting that the Notice of IDR initiation was sent to the non-initiating party)
• Member ID Card (if applicable)
• UB-04 Form (for bundled disputes using a DRG code)
• CMS extension documentation confirming extension approval
• Prior payment determination containing the same disputing parties, service code, and date cooling off period began