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Surprise medical bills occur when patients are treated by out-of-network (OON) providers under circumstances where they are unable to plan for or avoid the OON service (e.g., emergency care). Surprise bills can also occur when a patient is unknowingly treated by an out-of-network provider at an in-network facility such as a hospital. Usually, the out-of-network provider sends a bill to the patient鈥檚 insurance company, which pays a certain amount for the services. The remainder, or balance, of the bill is then sent to the patient.听

The NSA covers claims related to emergency services from the point of a patient鈥檚 evaluation and treatment until they were stabilized and can consent to being transferred to an in-network facility. It covers air ambulances but not ground ambulances.

The NSA also covers claims related to non-emergency services when they are provided at an in-network facility by an out-of-network provider.

The new law is effective for health plan years beginning on or after January 1, 2022.

QPA is a term introduced by the No Surprises Act (NSA). It is the plan鈥檚 median contracted rate for a specific service in the same geographic region within the same insurance market 鈥� the middle amount in an ascending or descending list of contracted rates, adjusted for market consumer price index in urban areas (CPIU). It鈥檚 important because it is one of the factors considered during the arbitration process if a provider does not agree with the payor鈥檚 initial payment, negotiations are unsuccessful and the Independent Dispute Resolution process is invoked.听 In most cases, the member cost share is based on QPA rather than the allowed amount. QPA is also used to determine member cost share.

Payors and providers go to arbitration under the NSA when they cannot agree on the amount of a payment for the providers鈥� services.听 Before bringing a case to arbitration, the parties must try to negotiate a settlement on their own. Either party has up to 30 days after the payor makes an initial payment to begin the negotiation process, and the negotiation must be open for at least 30 days. If the two sides can鈥檛 negotiate a settlement, either party can initiate the independent dispute resolution (IDR) process, also known as arbitration.听

Yes. The Interim Final Rule (IFR) published in July 2021 and a FAQ published with the August 19, 2022 Final Rule made clear that the No Surprises Act applies to claims that don鈥檛 use a network. The requirements are primarily limited to emergency services and air ambulance services for health plans that do not use a provider network, or that use a partial network (e.g., providers only, but no facilities). However, the IFR also stated that agreements between the RBP vendor and a facility would have to be considered as an 鈥渋n network鈥� facility for purposes of identifying surprise bills. The FAQ further clarifies that these plans are expected to use the QPA as required under the NSA 鈥� to determine the member鈥檚 cost sharing and as disclosure to the provider with reimbursement. The departments direct these plans to use an eligible database to calculate QPA.

We recommend that the member contact their health plan or visit for information.

Under the No Surprises Act (NSA), the member鈥檚 cost share of claims that qualify as surprise bills must be based on what the new law calls the Recognized Amount (RA). For most ERISA plans, the RA is the lesser of billed charges or the Qualifying Payment Amount. For insured claims regulated under state surprise bill laws or All-Payer Model Agreements, or ERISA plans that have opted in to such laws, the RA may be determined by the state law.听

The requirement relating to machine readable files is related to the Transparency in Coverage mandate, not the NSA. The mandate requires health plans to post the following files publicly in non-proprietary machine听

readable format and update the files monthly.听

• In-network negotiated rate files听
• Out-of-network allowed amount files听
• In-network negotiated prescription drug files听

听

The effective date of this requirement has been postponed from January 1, 2022 to July 1, 2022.听