Currentcare_continuumPolicy n05711

Balance Billing Policy

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Defines Network Health's rules prohibiting providers from balance billing members/participants except for specified member liabilities (deductible, coinsurance, copays) and describes refund and prior-authorization requirements; applies to all lines of business including Commercial and Medicare Advantage.

Policy Summary

Payercare_continuum

PolicyBalance Billing Policy

Policy CodePolicy n05711

Change TypeNo material changes

Effective Date

Last ReviewNov 27, 2023

Next Review DateDec 2, 202652d

Key ActionSubmit a prior-authorization or pre-determination request to Network Health's Utilization Management department before services to determine medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

No balance billingNo balance billing

Exceptions listedMember payment exceptions

No Surprises ActFederal reference

Hold harmlessCommercial LOB

MA prohibitionMedicare Advantage

Balance Billing Rules and Obligations

Balance billing rules and obligations

When providers may or may not bill members/participants:

Providers may collect applicable deductible, coinsurance, or copayments as indicated in the member/participant's coverage document; exception: a provider may not collect these amounts from a Medicare Advantage member designated as a Qualified Medicare Beneficiary (Dual Eligible).

Providers may collect payment for services determined to be not medically necessary by Network Health's Utilization Management department or its designee through a prior authorization obtained before services are rendered.

Providers may collect payment for services specifically excluded in the member/participant's coverage document.

Providers may not bill members/participants the difference between the provider's billed charges and Network Health's allowed amount (i.e., no balance billing).

If a member/participant paid any dollar amount greater than what is indicated in the coverage document, Network Health will require the provider to issue a refund.

Network Health will require a provider to issue a refund and submit a claim on the member's/participant's behalf for any service that is not listed as an exclusion in the coverage document, or any service determined to be medically necessary by Network Health's Utilization Management department or its designee.

Federal No Surprises Act (Consolidated Appropriations Act, 2021) prohibits balance billing for certain non-participating providers and services (including non-participating emergency providers/facilities, non-participating ancillary services at participating facilities, and non-participating air ambulance providers); providers may not balance bill the difference of plan payment and member cost share.

Commercial lines: providers subject to Wisconsin 'hold harmless' statutes may not bill, charge, collect a deposit from, seek remuneration from, file or threaten to file with a credit reporting agency, or take recourse against a member for health care costs for which the member is not liable (per Wisconsin Statutes sections cited).

Medicare Advantage lines: providers may not balance bill members per the Medicare Managed Care Manual, Chapter 4, Section 170.2.

Provider Requirements and Prior Authorization

Prior Authorization

Submit prior-authorization / pre-determination for medical necessity

Provider may submit a prior-authorization or pre-determination request to Network Health's Utilization Management department before services are rendered to determine medical necessity. Prior authorization is required when the provider seeks a determination that a service is medically necessary and may affect whether the provider may collect payment from the member for services deemed not medically necessary.

Submit a prior-authorization or pre-determination request to Network Health's Utilization Management department prior to rendering services.
If Utilization Management determines a service is not medically necessary via prior authorization, the provider may collect payment from the member for that service; if Utilization Management determines the service is medically necessary, Network Health will require the provider to issue a refund and submit a claim on the member's behalf.

Key Definitions and Member Liabilities

inv-03: Balance billing — definition / explanation of balance billing / surprise billing

Federal requirementThe Consolidated Appropriations Act (2021) / No Surprises Act (effective 1/1/2022) prevents balance billing for certain out-of-network emergency services, non-participating ancillary services at participating facilities, and non-participating air ambulance services.

inv-04: Member liability exceptions — Member liabilities that providers may collect include applicable deductible, coinsurance, or copayments as indicated in the member's coverage

Medicare Advantage exceptionProviders may not collect these liabilities from a Medicare Advantage member who has been designated as a Qualified Medicare Beneficiary (Dual Eligible).

Policy Summary

Payercare_continuum

PolicyBalance Billing Policy

Policy CodePolicy n05711

Change TypeNo material changes

Effective Date

Last ReviewNov 27, 2023

Next Review DateDec 2, 202652d

Key ActionSubmit a prior-authorization or pre-determination request to Network Health's Utilization Management department before services to determine medical necessity.

SourceLink

On This Page

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Balance Billing Policy

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Balance Billing Rules and Obligations

Balance billing rules and obligations

When providers may or may not bill members/participants:

Providers may collect payment for services specifically excluded in the member/participant's coverage document.

Providers may not bill members/participants the difference between the provider's billed charges and Network Health's allowed amount (i.e., no balance billing).

If a member/participant paid any dollar amount greater than what is indicated in the coverage document, Network Health will require the provider to issue a refund.

Medicare Advantage lines: providers may not balance bill members per the Medicare Managed Care Manual, Chapter 4, Section 170.2.

Provider Requirements and Prior Authorization

Prior Authorization

Submit prior-authorization / pre-determination for medical necessity

Submit a prior-authorization or pre-determination request to Network Health's Utilization Management department prior to rendering services.
If Utilization Management determines a service is not medically necessary via prior authorization, the provider may collect payment from the member for that service; if Utilization Management determines the service is medically necessary, Network Health will require the provider to issue a refund and submit a claim on the member's behalf.

Key Definitions and Member Liabilities

inv-03: Balance billing — definition / explanation of balance billing / surprise billing

inv-04: Member liability exceptions — Member liabilities that providers may collect include applicable deductible, coinsurance, or copayments as indicated in the member's coverage

Medicare Advantage exceptionProviders may not collect these liabilities from a Medicare Advantage member who has been designated as a Qualified Medicare Beneficiary (Dual Eligible).