These regulations intend to protect members from certain unexpected bills for out-of-network emergency services, care by out-of-network providers at an in-network facility and out-of-network air ambulance services.
1. Participate in Independent Dispute Resolution process for out-of-network provider reimbursement disputes involving No Surprises Act items and services
Provider reimbursement is the payment that a provider, such as a doctor or hospital, receives from a patient’s insurance company for giving the member medical services. The new legislation creates an Independent Dispute Resolution (IDR) process for No Surprises Act items and services. This can be triggered by either the insurance company or the out-of-network provider when there is a reimbursement disagreement.
The federal government operates the IDR process with the insurance company and out-of-network provider submitting reimbursement information to a certified IDR entity for resolution. The certified IDR entity’s determination is binding on the insurance company and out-of-network provider.
Who it applies to:
- Individual policies
- Fully insured group health plans
- Self-funded group health plans (including grandfathered)
Effective date: Plan years beginning on or after Jan. 1, 2022
Action required: No member or employer group action is needed at this time; changes will be made within BCBSND systems and administrative processes
