Starting Jan. 1, 2022, members enrolled in commercial health care coverage offered or administered by BlueCross will have new protections from unexpected medical bills for certain emergency and ancillary services from out-of-network providers. They’ll also have new protections for covered services provided by out-of-network providers at an in-network facility.  (These provisions do not apply to individuals enrolled in Medicare Advantage Plans or Medicaid managed care plans, such as BlueCare.)

Members shouldn’t get surprise medical bills when they get out-of-network care for:

• Emergency services at an out-of-network hospital ER or freestanding ER
• Non-emergency, ancillary services from an out-of-network provider furnished at an in-network facility
  • These can include anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist and intensivist services.
• Non-emergency services furnished by non-ancillary providers unless the member receives notice of, and provides consent to, treatment by the provider and balance billing.
• Out-of-network air ambulance transport if the services would have been covered if provided by an in-network air ambulance provider.

Please consult your legal representative for a complete list of the services that are protected.

To submit additional claims information electronically, follow the Supplemental EDI Information guidelines and complete the PWK Fax Cover Sheet.

The CAA prohibits out-of-network providers from balance billing members for these covered services: emergency services, non-emergency services furnished by out-of-network providers at in-network facilities, and air ambulance services. We’ll refer to these as Protected Services, meaning the member is generally protected from balance billing.

In some instances, providers can balance bill for some of these Protected Services, but only after a provider gives a member a consent form, and the member signs the form. Not all Protected Services are eligible for balance billing after obtaining a member’s consent, such as, but not limited to, covered emergency services (excluding post-stabilization services), covered air ambulance services, anesthesia, pathology, radiology, laboratory, neonatology, and also assistant surgeon, hospitalist and intensivist covered services.

The U.S. Department of Health and Human Services (HHS) has issued additional regulations and information for providers regarding required notice and consent documents, along with instructions on how to provide these documents to patients.

Information we’re required to share with out-of-network providers relating to Protected Services and the Qualified Payment Amount (QPA)

The member’s cost-sharing for Protected Services is calculated based on the “recognized amount,” which is defined by federal regulations. We’ve determined that in Tennessee the recognized amount is the lesser of the QPA and the provider’s billed amount.

When the recognized amount is the QPA, federal law requires us to provide you with certain information about the QPA:

• The QPA for an item or service is identified on the remittance advice, with an appropriate explanation code.
• If the QPA is based on a downcoded service code or modifier, the original procedure code and its accompanying QPA.
• The QPA is defined in federal law and, generally speaking, is considered the median contract rate for an item or service furnished by a similar provider or facility in the same insurance market.
• BlueCross determines the QPA for each item and service using a good faith, reasonable interpretation of federal regulations.
• A provider who’s not satisfied with their payment from BlueCross for a Protected Service can begin the open negotiation period provided under federal law within 30 business days of the initial payment or notice of denial from BlueCross.
• A provider must initiate the independent dispute resolution (IDR) process within four business days after the end of the open negotiation period.

Open Negotiation and Independent Dispute Resolution

Open Negotiation Process

To initiate open negotiation with BlueCross, you must complete and email the federally required Open Negotiation Notice form to BlueCross at CAA_OpenNegNotice@bcbst.com. In addition, please return the BlueCross Open Negotiation Notice Supplemental Information Form, so we have everything we need to review your request. Links to these forms can be found below.

If you have questions about this open negotiation process, please call Provider Service at 1-800-924-7141 or email us at CAA_OpenNegNotice@bcbst.com.

Independent Dispute Resolution (IDR)

To initiate IDR, you must submit the applicable form to the federal government’s IDR Portal, and also submit a copy of the same form to BlueCross on the same day. Please include any attachments and information sufficient to identify the services in the dispute. All information should be sent by email to nsaidr@multiplan.com.

Here are the links to the forms to initiate the 30-business-day open negotiation period:

Federal Open Negotiation Notice Form
BlueCross Open Negotiation Notice Supplemental Information Form