The No Surprises Act: Information for Providers

In 2021, Congress passed the Consolidated Appropriations Act, commonly known as the No Surprises Act (NSA). This Act protects consumers from unexpected medical bills for services rendered by out-of-network providers.

Before passage of the Act, consumers might be billed for the difference between the actual cost of out-of-network services and what their insurer paid for them. These so-called “surprise bills” were especially common in situations where a patient needed emergency care and used an out-of-network provider. Surprise billing also occurred when patients received care from an out-of-network provider at an in-network facility, and out-of-network air ambulance services.¹

Under the Act, the following rules apply:²

• Surprise bills for emergency services, including those from out-of-network providers and without prior authorization, are banned.
• Out-of-network cost sharing, including out-of-network coinsurance or copayments, is banned for “most emergency and some non-emergency services.”²
• Charges for services and balance bills for additional services provided by out-of-network providers at in-network facilities are banned. These may include anesthesiology or radiology.
• Health care providers and facilities are required to give patients easy-to-understand notices that explain billing protections, name who should be contacted if violations occur, and state that “patient consent is required to waive billing protections.”²

Visit the Centers for Medicare & Medicaid Services (CMS) website for additional information.

Open negotiation request

Under the NSA, an out-of-network provider may file an open negotiation notice with AmeriHealth Caritas Next within 30 business days of receiving initial payment or denial of payment. This notice will begin the 30-day open negotiation period.³

The open negotiation period was established to give both parties an opportunity to resolve their dispute without having to enter the Federal Independent Dispute Resolution (IDR) process. This allows them to avoid Federal IDR filing fees as well as provides an opportunity to review the claim to see if it is eligible for Federal IDR.⁴

Services that are covered by the No Surprises Act, and that are subject to an open negotiation request, are limited to:⁵

• Emergency services (including post-stabilization services) provided at a non-participating facility
• Non-emergency services performed by a non-participating provider at a participating facility
• Air ambulance services provided by non-participating providers

During the open negotiation period, AmeriHealth Caritas Next will work with the provider in an attempt to arrive at an agreed-upon amount for the total out-of-network rate. Providers should use one Open Negotiation Notice per each out-of-network item or service, unless AmeriHealth Caritas Next made an initial payment as a bundled payment (or specifies that a denial of payment is made on a bundled payment basis) or the provider intends to batch all the items or services included in the notice, as permitted under the interim final rules as part of the Federal IDR process.

To file an open negotiation request, complete the request form and email it to NextProviderOpenNegotiations@amerihealthcaritas.com. A negotiator from AmeriHealth Caritas Next will contact you.