Surprise bill disputes

Important information regarding No Surprises Act open negotiation and Independent Dispute Resolution (IDR)

Providers and facilities may be eligible to request an open negotiation period under the No Surprises Act. Plan sponsors of the group health plan may use various entities to manage their No Surprises Act negotiations and independent dispute resolution processes. To learn more about the open negotiation process, payment amounts or to request a 30-business-day open negotiation period, you can:

• Refer to your remittance advice document for the claim in question
• Sign into the healthscopebenefits.com provider portal and enter the claim number to see the remittance adviceCall the provider phone number on the patient’s member ID card

Providers and facilities may also be eligible to use the IDR process following the open negotiation period, subject to eligibility requirements and deadlines.  Responsibility for payments resulting from the IDR process remains with the group health plan.

If a payment amount remains unresolved, you may initiate the IDR process within 4 business days after the end of the negotiation period by emailing the entity as shown on the remittance advice.

Note: For outpatient facility claims priced at the claim level (for example, bundled claims), each service code’s qualified payment amount (QPA) represents a proportional share of the total claim QPA.  This information may be helpful when revising claim repricing and payment determinations.