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Spotlight Mandate: New requirements for out-of-network provider reimbursement disputes

Provider reimbursement is the payment that a provider, such as a doctor or hospital, receives from a health plan for giving medical services. This new legislation creates an Independent Dispute Resolution (IDR) process for services outlined by the No Surprises Act that can be triggered by either the health plan or the out-of-network provider when there is a reimbursement disagreement.

The federal government operates the IDR process, with the health plan 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 health plan and out-of-network provider. The IDR process does not affect the member, and no matter the outcome, the member cannot be balance billed.

Who it applies to: Fully insured group health plans, self-funded group health plans, and individual policies – including all grandfathered plans.

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 to BCBSND’s relevant administrative processes.