Qualified services and items for the federal No Surprises Act
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Notifies out-of-network providers and facilities about how Wellsense applies the No Surprises Act to qualified services/items, how to find the Qualified Payment Amount (QPA), and how to initiate open negotiation and Independent Dispute Resolution (IDR). Affects out-of-network providers and facilities billing Wellsense members.
No material clinical or coverage changes in this revision.
No Surprises Act Qualified Services & Items
No Surprises Act qualified services/items
Wellsense stance and procedures for No Surprises Act qualified services/items:
ALL of the following
- Qualified Payment Amount (QPA) for No Surprises Act qualified services/items is reported on the Remittance Advice.
- QPA applies for purposes of the Recognized Amount (or, for air ambulance services, for calculating the member's cost‑sharing liability).
- QPAs are based on 45 CFR 149 et seq.
ALL of the following
- Providers may initiate a 30‑business‑day open negotiation period by submitting a completed Open Negotiation Notice using the federally required form.
- The Open Negotiation Notice must be submitted by email or mail within 30 business days of your receipt of Wellsense's initial payment or notice of payment denial for the qualified services/items.
- Send the Open Negotiation Notice to: WellSense Health Plan, Attn: Provider Contracting Dept., Schrafft's City Center, 529 Main Street, Charlestown, MA 02129; Email: Provider.info@wellsense.org; Phone: 888-566-0008.
- The open negotiation period begins on the day Wellsense receives the Open Negotiation Notice.
ALL of the following
- If no agreement is reached following the 30‑business‑day negotiation period, providers may initiate the federal Independent Dispute Resolution (IDR) process.
- To initiate IDR, submit the federally required Notice of IDR Initiation form during the 4‑business‑day period beginning on the 31st business day after the start of the open negotiation period to the address in the Open Negotiation instructions above.
QPA, Negotiation & IDR Timing
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How Providers Initiate Negotiation and IDR
Initiate open negotiation and, if needed, IDR
Providers may initiate a 30-business-day open negotiation by submitting a completed Open Negotiation Notice (the federally required form) within 30 business days of receipt of Wellsense’s initial payment or notice of payment denial for qualified services or items. If no agreement is reached after the 30-business-day negotiation period, providers may initiate the federal Independent Dispute Resolution (IDR) process by submitting a Notice of IDR Initiation (the federally required form) during the 4-business-day period beginning on the 31st business day after the start of the open negotiation period.
- Open Negotiation Notice must be submitted by email or mail using the federally required form within 30 business days of receipt of initial payment or denial.
- Notice of IDR Initiation must be submitted during the 4-business-day period beginning on the 31st business day after negotiation start using the federally required form.
Submission contact information for Open Negotiation and IDR notices
Submit Open Negotiation Notices and Notices of IDR Initiation to WellSense Health Plan at the address, email, or phone number listed below. The open negotiation notice period begins on the day you send the Open Negotiation Notice.
- Mail: WellSense Health Plan, Attn: Provider Contracting Dept., Schrafft's City Center, 529 Main Street, Charlestown, MA 02129
- Email: Provider.info@wellsense.org
- Phone: 888-566-0008
Key Terms
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.