Currentpriority healthPolicy N/A

Balance-billing and disclosure requirements for nonparticipating providers

Governs Michigan requirements for nonparticipating (out-of-network) providers when treating nonemergency patients, including disclosure, good-faith cost estimates, record retention, and payment dispute/limitation rules that affect patient liability and carrier reimbursement.

Policy Summary

Payerpriority health

PolicyBalance-billing and disclosure requirements for nonparticipating providers

Policy CodePolicy N/A

Change TypeStatutory requirements added

Effective DateOct 22, 2020

Next Review DateN/A

Key ActionProvide the required written disclosure in 12-point type, obtain patient signature, give a good-faith cost estimate, and retain the disclosure for at least 7 years.

SourceLink

POLICY UPDATE CHANGES

Nonparticipating providers must give a written disclosure to nonemergency patients and obtain a signed acknowledgement before care in most non-emergent settings.

Nonparticipating providers must provide a good-faith estimate of the cost of services and retain the disclosure for at least 7 years.

If a nonparticipating provider fails to provide the required disclosure, they must submit a claim to the patient's carrier and accept payment based on specified formulas.

14 daysminimum advance notice for scheduled services in many facility types

12-pointminimum font size required for disclosure text

7 yearsrequired retention period for the disclosure document

60 daystimeframe for provider to submit claim / carrier to pay

150% Medicarealternative payment benchmark when disclosure not provided

Coverage and Payment Criteria

Disclosure and payment criteria

When a nonparticipating provider treats a nonemergency patient:

Provide the written disclosure in not less than 12-point type using substantially the prescribed language and obtain the nonemergency patient’s or the patient’s representative’s signature on the disclosure acknowledging receipt, reading, and understanding.

Timing (provide disclosure at the earliest of)

For services scheduled and provided in a facility described in section 24502(7)(a), (b), (c), (e), or (f): provide the disclosure at least 14 days before the service or, if the service will be provided within 14 days after scheduling, within 14 days.
If the service is being provided in a facility described in section 24502(7)(d): provide the disclosure at the time of the nonparticipating provider’s first contact with the nonemergency patient regarding the service.
Or during one of the following pre-service contacts

Policy Summary

Payerpriority health

PolicyBalance-billing and disclosure requirements for nonparticipating providers

Policy CodePolicy N/A

Change TypeStatutory requirements added

Effective DateOct 22, 2020

Next Review DateN/A

Key ActionProvide the required written disclosure in 12-point type, obtain patient signature, give a good-faith cost estimate, and retain the disclosure for at least 7 years.

SourceLink

On This Page

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Provider Disclosure, Estimates, and Claims Actions

Documentation Required

Provider Disclosure, Estimates, and Claims Actions

Nonparticipating providers must follow Michigan law regarding disclosure, good-faith estimates, and timely claims submission for nonemergency patients. Provide the required written disclosure in at least 12-point type and obtain the patient or patient representative's signature acknowledging receipt, understanding, and that the patient may be responsible for costs not covered by their health plan. Provide a good-faith estimate of the cost of the health care services (noting the estimate excludes unforeseen circumstances). Retain a copy of the signed disclosure for at least 7 years. If the disclosure is not provided as required, submit a claim to the member's carrier within 60 days of the service and accept payment from the carrier as full payment equal to the greater of: (1) the regional, specialty median negotiated amount determined by the carrier (excluding in‑network cost sharing), or (2) 150% of the Medicare fee‑for‑service amount for the service (excluding in‑network cost sharing). The carrier must pay the nonparticipating provider within 60 days of receiving the claim. Providers may only collect applicable in‑network coinsurance, copayment, or deductible from the patient.

Disclosure must be in ≥12-point type and include statement that plan may not cover all services
Obtain patient or representative signature on disclosure and retain for ≥7 years
Provide a good-faith estimate of expected costs (excludes unforeseen circumstances)
If disclosure not provided, submit claim to carrier within 60 days of service
Carrier payment to provider: greater of regional specialty median negotiated amount OR 150% of Medicare FFS; carrier pays within 60 days
Provider may only collect applicable in‑network coinsurance, copayment, or deductible from patient

Key Definitions

inv-04: A provider not participating in the patient's health benefit plan network (implicit from statute context)

ApplicabilityApplies when the nonparticipating provider is providing a health care service to a nonemergency patient and must follow disclosure and related requirements in Sec. 24509.

inv-05: A patient receiving nonurgent health care services (statute addresses nonemergency situations and timing)

Definition: Nonemergency patientA patient receiving nonurgent health care services for which the statute requires advance disclosure and timing rules (i.e., scheduled or presurgical contexts described in Sec. 24509).

Timing rulesFor services in specified facility types, disclosure must be provided at least 14 days before the service or within 14 days if service occurs within 14 days of scheduling; other settings require disclosure at first contact or during presurgical/scheduling/intake/preop review.

Exclusion at admissionDisclosure must not be provided at the time of admittance to certain facilities or at the time of preparing the patient for surgery in those facilities (see Sec. 24509(2)).

inv-06: An estimated cost of the health care services that does not account for unforeseen circumstances

Provider dutyNonparticipating providers must provide the nonemergency patient or their representative with a good-faith estimate of the cost of the services to be provided.

Record retention relevanceThe statute requires retention of the disclosure (which includes the estimate) for at least 7 years, supporting audit and dispute resolution for the estimate provided.

OpenPayer

Balance-billing and disclosure requirements for nonparticipating providers

Coverage and Payment Criteria

Provider Disclosure, Estimates, and Claims Actions

Payment Benchmarks and Reimbursement

Key Definitions