CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Consolidated Appropriations Act (CAA) — No Surprises Act FAQs

Provides Blue Cross Blue Shield of South Carolina's FAQ guidance on No Surprises Act requirements (surprise billing bans, independent dispute resolution, member ID card changes, advanced explanations of benefits, and provider directory validation) for members, providers, and plan administrators.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyConsolidated Appropriations Act (CAA) — No Surprises Act FAQs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionTreat emergency services as in-network without prior authorization and disclose if proposed services require medical management in the Advanced Explanation of Benefits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysProvider validation

1 dayAEB (3-9 days)

3 daysAEB (10+ days)

member cardID card fields

No Surprises Act Operational Criteria

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No Surprises Act operational criteria

Coverage stance and operational criteria derived from the No Surprises Act FAQs:

ALL of the following

Emergency services must be treated as in-network without requirements for prior authorization.
Based on federal No Surprises Act emergency service protections.
Patient cost-sharing for emergency and non-emergency services cannot exceed amounts that would apply if the services were provided in-network; any coinsurance or deductible must be based on in-network provider rates.
Limits on out-of-network cost-sharing per No Surprises Act.
Ancillary services provided at an in-network facility may not bill the patient at out-of-network rates.
Prohibits out-of-network ancillary charges at in-network facilities.
Providers must give a plain-language notice and obtain patient consent before billing at out-of-network rates (advance notice requirement).
Consent and notice required prior to out-of-network billing.

ALL of the following

AEB must include whether the provider or facility is in-network or out-of-network.
AEB must include the contracted (in-network) rate for the service if applicable, or information on where to find in-network provider/facility information if out-of-network.
AEB must include a good-faith estimate from the provider or facility based on applicable medical billing codes.
AEB must include an estimate of the amount payable under the plan and the patient’s cost-sharing responsibility, including accrued amounts toward deductibles and out-of-pocket maximums.
AEB must state whether the proposed service is subject to medical management (prior authorization, concurrent review, fail-first protocols).
AEB must include a disclaimer that listed costs are estimates and any other information deemed appropriate by plan administrators.

AEB submission timing

If the patient schedules the service 3–9 days before the intended date of service, the plan must submit the AEB within 1 business day after notification from the provider or facility.1 business day
If the patient schedules the service 10 or more days before the intended date of service, the plan must submit the AEB within 3 business days after notification.3 business days

ALL of the following

ID cards must list all plan deductibles (both in-network and out-of-network).
ID cards must list out-of-pocket maximums (both in-network and out-of-network).
ID cards must include a phone number and web address for consumer information, including where to find in-network providers.

ALL of the following

Providers must verify their demographic data at least every 90 days.90 days
If more than 90 days has passed since the provider’s last validation, the provider will be suppressed from the public provider directory.
Suppression required for nonvalidation beyond 90 days.

ALL of the following

An IDR process is available to determine out-of-network rates for certain services; the process is between the provider and the plan and does not involve the patient.
IDR form and submission information provided by payer.

Provider Responsibilities and Prior Authorization

Prior Authorization

Treat emergency services as in‑network; disclose medical‑management requirements in the AEB

Emergency services must be treated as in‑network and may not be subject to prior authorization; providers must disclose in the Advanced Explanation of Benefits if a proposed service is subject to medical management (for example, prior authorization, concurrent review, or fail‑first protocols).

Emergency services: treated on an in‑network basis without requirements for prior authorization.
Advanced Explanation of Benefits must state whether the proposed service is subject to medical management (prior authorization, concurrent review, fail‑first).

Key Terms

Surprise billing — definition

DefinitionSurprise billing is when a patient receives an unexpected bill from a health care provider or facility, often from receiving care outside the plan's network.

ContextsCan occur during both emergency and non‑emergency care

CauseOften happens when patient unknowingly obtains care from an out‑of‑network provider or facility

Independent dispute resolution (IDR) — definition

DefinitionThe independent dispute resolution (IDR) process may be used to determine out‑of‑network rates for certain emergency services, nonemergency items and services at participating facilities, and air ambulance services when applicable; the patient/member is not involved.

ScopeApplies to nonparticipating providers at participating facilities and certain air ambulance services where other agreements or state law do not apply

Form & submissionIDR form available on SouthCarolinaBlues.com and BlueChoiceSC.com; can be mailed or emailed to specified addresses

OpenPayer

Consolidated Appropriations Act (CAA) — No Surprises Act FAQs

No Surprises Act Operational Criteria

Advanced Explanation of Benefits (AEB) and Coding

Provider Responsibilities and Prior Authorization

Key Terms