The No Surprises Act protects patients from balance billing.
In balance billing, an out-of-network provider charges for the leftover amount after the health plan pays its share. An unexpected balance bill is called a surprise bill.
Dispute a Qualifying Payment Amount
Providers can initiate the open negotiation process by completing the Qualifying Payment Amount (QPA) Dispute Form.
Other ways to initiate Open Negotiation
Email - Send a completed Federal Open Negotiation Template to QPA@bcbsnc.com.
Mail - Send a completed Federal Open Negotiation Template to:
Network Management - Surprise Billing
PO Box 2291
Durham NC 27707
If you need additional assistance, please call: (888) 302-0530.
More Information
What scenarios are members considered to be held harmless?
The No Surprises Act now holds members harmless from surprise bills when receiving:
- OON emergency services:
- OON emergency room visits
- OON inpatient admissions from the emergency room
- OON observations admissions from the emergency room
- OON air ambulance services
- Services from OON hospital-based providers at INN facilities, such as Anesthesia, Radiology, etc.
What claims do not apply to the No Surprises act?
- Date of service prior to January 1, 2022
- Medicare Advantage plans
- Plans not subject to U.S. law
- Retiree-only plans
- State Medicaid plans
How do I know whether or not a claim is considered a Surprise Billing claim?
On the first page of your EOP there is a remarks box that lists codes. Code X00 means “This claim is subject to Surprise Billing Legislation Protections.” Additional disclosure information is provided. Throughout the following pages, if the ‘Remark Code’ column states X00, it is a Surprise Billing claim.
How do I know what the QPA amount is?
The QPA is listed in the Contracted Charges column of your EOP.
How can I learn more about your QPA Methodology?
Email QPA@bcbsnc.com to learn more about the QPA Methodology.
What if we don’t come to an agreement at the end of Open Negotiation?
If we cannot come to an agreement after 30 business days, you may pursue the independent dispute resolution (IDR) process designed by the Centers for Medicare & Medicaid Services (CMS) as outlined in the No Surprises Act and regulations pursuant to the Act.
Will providers be able to appeal denied claims?
The appeals team will follow their normal appeals process. However, appeals will not review the following in terms of Surprise Billing:
- Requests for an appeal following a voluntary notification review Observation recommendation. This is not an adverse benefit determination and is only a recommendation at this specific stage.
- Requests for an appeal related to QPA pricing. Providers must initiate the open negotiation process.
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