CurrentAlabama Department of InsurancePolicy 2022-01

Federal No Surprises Act — Provider, Facility, and Air Ambulance Requirements (Guidance)

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Guidance from the Alabama Department of Insurance on federal No Surprises Act protections and provider/facility obligations effective January 1, 2022; intended for health care providers, facilities, and air ambulance service providers operating in Alabama.

Policy Summary

PayerAlabama Department of Insurance

PolicyFederal No Surprises Act — Provider, Facility, and Air Ambulance Requirements (Guidance)

Policy CodePolicy Policy 2022-01

Change TypeGuidance bulletin (no material changes)

Effective DateJan 1, 2022

Next Review Date

Key ActionProviders, facilities, and air ambulance providers must follow NSA requirements and may use the federal independent dispute resolution process when out-of-network negotiations fail, meeting all procedural deadlines and attestations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8major requirement areas summarized

Jan 1, 2022NSA effective date

Federal NSAauthoritative source

No Surprises Act: Provider & Facility Requirements

inv-01: NSA provider/facility requirements

Provider and facility obligations and billing prohibitions under the No Surprises Act

Providers, facilities, and air ambulance providers must comply with the No Surprises Act protections and related federal regulations (effective January 1, 2022).

See specific prohibitions and requirements below.

Prohibition — Out‑of‑network emergency services: May not balance bill enrollees for out‑of‑network emergency services; nonparticipating providers and nonparticipating emergency facilities cannot bill or hold liable enrollees for amounts greater than the in‑network cost‑sharing for emergency department services. Post‑stabilization services are treated as emergency services and are subject to this prohibition unless the notice and consent exception applies.

[See conditions and notice/consent exception].

Exception — Notice and consent for post‑stabilization/non‑emergency

The attending emergency physician or treating provider determines the enrollee can travel using nonmedical transportation to an available participating provider or facility within a reasonable travel distance given the individual’s medical condition and is in a condition to receive notice and provide informed consent.
The nonparticipating provider or facility provides the enrollee with the written notice and obtains informed consent as required by the NSA regulation and guidance.
The provider or facility satisfies any additional applicable state law requirements.

Prohibition — Non‑emergency services at participating facilities: Nonparticipating providers of non‑emergency services at participating health care facilities may not balance bill enrollees for amounts greater than in‑network cost‑sharing, unless the valid notice and consent exception is satisfied.

The notice and consent exception does not apply to certain ancillary services (emergency medicine, anesthesiology, pathology, radiology, neonatology), assistant surgeons, hospitalists, intensivists, diagnostic services (including radiology and laboratory), or where no participating provider is available.

Prohibition — Air ambulance services: Nonparticipating air ambulance providers may not bill or hold liable enrollees for covered air ambulance services for amounts greater than the in‑network cost‑sharing requirement.

Good faith estimate — insured and uninsured individuals: Providers and facilities must, once rules are in place, provide a good faith estimate in advance of scheduled services or upon request. Upon scheduling or request, providers must ask whether the individual has coverage; if the individual has coverage and plans to submit a claim, the provider must provide the individual’s plan or issuer a good faith estimate of expected charges and expected billing/diagnostic codes for the primary service and items or services reasonably expected to be provided (including by other providers/facilities). For uninsured or self‑pay individuals, providers must give a good faith estimate directly, including information on the patient‑provider dispute resolution process and applicable dollar threshold for eligibility.

Dollar threshold for dispute resolution is determined by federal regulation or applicable state law.

Directory accuracy and reimbursement: Providers and facilities with network contracts must submit accurate provider directory information at required times (e.g., at network entry, termination, material changes, upon request) and must reimburse enrollees who relied on an incorrect directory and paid amounts in excess of in‑network cost‑sharing.

Dispute resolution — Independent Dispute Resolution (IDR): Providers, facilities, and air ambulance providers may use the federal independent dispute resolution process for certain out‑of‑network claims when negotiations do not produce an agreed payment. Participants must meet procedural requirements, including deadlines, attestations of no conflicts of interest, choosing a certified IDR entity, submitting a payment offer, and providing required information.

More information will be available through CMS No Surprises Act resources.

Estimates, Thresholds, and Coding-related Items

Good faith estimate content requirementsmixed

No codes listed

Dollar threshold for dispute resolution eligibility

Dollar threshold for patient-provider dispute resolution eligibilityDetermined by federal regulation or applicable state law (the good faith estimate dispute process applies when the difference between the GFE and the bill meets the dollar threshold established in federal regulation or, for states with a balance-billing law, the state dollar threshold and payment methodology).

Source of threshold determinationFederal regulation sets the default threshold; states with their own balance-billing laws may specify an alternate threshold and payment methodology.

Where threshold is referenced in processIncluded in the good faith estimate notification to uninsured/self-pay individuals as the amount that makes the patient eligible to use the patient-provider dispute resolution process.

Dispute Resolution and Actionable Processes

Prior Authorization

Use federal Independent Dispute Resolution (IDR) when negotiations fail

The No Surprises Act establishes a federal independent dispute resolution (IDR) process that providers, facilities, and air ambulance providers may use to resolve certain out‑of‑network claims when negotiations fail. Use of the IDR requires meeting procedural deadlines, attesting there are no conflicts of interest, selecting a certified IDR entity, submitting a payment offer, and providing any additional requested information.

Meet required deadlines for initiating and participating in the IDR process.
Attest to absence of conflicts of interest as part of the submission.
Select and use a certified independent dispute resolution entity.
Submit a payment offer and provide additional information if requested.

Key Definitions and Exceptions

Prohibition on balance billing (No balance billing)

No balance billing for emergency servicesNonparticipating providers and nonparticipating emergency facilities may not bill enrollees more than the in-network cost-sharing amount for out-of-network emergency services, including post-stabilization services unless notice and consent conditions are met.

No balance billing for certain non-emergency services at participating facilitiesNonparticipating providers of non-emergency services at participating health care facilities cannot bill enrollees more than in-network cost-sharing for covered non-emergency services, unless valid notice and consent applies (with specified exceptions).

No balance billing for air ambulance servicesNonparticipating air ambulance providers cannot bill enrollees more than the in-network cost-sharing amount for covered air ambulance services.

Ancillary service carve-outsThe notice-and-consent exception does not apply to certain ancillary services (e.g., emergency medicine, anesthesiology, pathology, radiology, neonatology, assistant surgeons, hospitalists, intensivists, diagnostic services) — the prohibition remains for these services.

Notice and consent exception (when balance billing may be permitted)

Notice and consent for post-stabilization servicesNonparticipating providers/facilities may bill for post-stabilization services only if the attending provider determines the enrollee can travel to a participating provider within a reasonable distance and is able to receive notice and provide informed consent, and written notice and consent are obtained per NSA regulations.

Written notice requirementThe nonparticipating provider or facility must provide the beneficiary/enrollee with the written notice specified in the NSA regulation and obtain the individual’s informed consent as outlined in the regulation and guidance.

State law complianceProviders/facilities must also satisfy any additional state law requirements for the notice-and-consent exception to apply.

Exception limitationsThe notice-and-consent exception does not apply to certain ancillary services or when no participating provider is available to provide the service at the facility.

Good faith estimate (GFE) requirements

Good faith estimate to plans/issuers when patient has coverageIf an individual has coverage and plans to submit a claim, the provider or facility must provide the individual’s plan or issuer a good faith estimate of expected charges for the scheduled item or service and any reasonably expected related items or services, including expected billing and diagnostic codes.

Good faith estimate to uninsured/self-pay individualsFor individuals without insurance or those not filing a claim, providers/facilities must provide a good faith estimate in advance of scheduled services or upon request, including information about the patient-provider dispute resolution process where applicable.

Contents required in the GFEThe estimate must include expected charges for the primary item/service and items/services reasonably expected to be provided together, including those from other providers/facilities, with expected billing and diagnostic codes.

Policy Summary

PayerAlabama Department of Insurance

PolicyFederal No Surprises Act — Provider, Facility, and Air Ambulance Requirements (Guidance)

Policy CodePolicy Policy 2022-01

Change TypeGuidance bulletin (no material changes)

Effective DateJan 1, 2022

Next Review Date

SourceLink

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Federal No Surprises Act — Provider, Facility, and Air Ambulance Requirements (Guidance)

Customize your policy alerts

Sign up for Alabama Department of Insurance Policy 2022-01 alerts

Get alerted when Policy 2022-01 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

No Surprises Act: Provider & Facility Requirements

inv-01: NSA provider/facility requirements

Provider and facility obligations and billing prohibitions under the No Surprises Act

Providers, facilities, and air ambulance providers must comply with the No Surprises Act protections and related federal regulations (effective January 1, 2022).

See specific prohibitions and requirements below.

[See conditions and notice/consent exception].

Exception — Notice and consent for post‑stabilization/non‑emergency

The attending emergency physician or treating provider determines the enrollee can travel using nonmedical transportation to an available participating provider or facility within a reasonable travel distance given the individual’s medical condition and is in a condition to receive notice and provide informed consent.
The nonparticipating provider or facility provides the enrollee with the written notice and obtains informed consent as required by the NSA regulation and guidance.
The provider or facility satisfies any additional applicable state law requirements.

Dollar threshold for dispute resolution is determined by federal regulation or applicable state law.

More information will be available through CMS No Surprises Act resources.

Estimates, Thresholds, and Coding-related Items

Good faith estimate content requirementsmixed

No codes listed

Dollar threshold for dispute resolution eligibility

Source of threshold determinationFederal regulation sets the default threshold; states with their own balance-billing laws may specify an alternate threshold and payment methodology.

Dispute Resolution and Actionable Processes

Prior Authorization

Use federal Independent Dispute Resolution (IDR) when negotiations fail

Meet required deadlines for initiating and participating in the IDR process.
Attest to absence of conflicts of interest as part of the submission.
Select and use a certified independent dispute resolution entity.
Submit a payment offer and provide additional information if requested.

Key Definitions and Exceptions

Prohibition on balance billing (No balance billing)

No balance billing for air ambulance servicesNonparticipating air ambulance providers cannot bill enrollees more than the in-network cost-sharing amount for covered air ambulance services.

Notice and consent exception (when balance billing may be permitted)

State law complianceProviders/facilities must also satisfy any additional state law requirements for the notice-and-consent exception to apply.

Exception limitationsThe notice-and-consent exception does not apply to certain ancillary services or when no participating provider is available to provide the service at the facility.

Good faith estimate (GFE) requirements