Where can providers submit an Open Negotiation Notice or a Notice of IDR Initiation to UPMC Health Plan?
Pennsylvania providers and all providers outside of Ohio:
Requests and inquiries should be submitted to: UPMC_NSA_Dispute@upmc.edu
Please use secure email for PHI
Requests and inquiries should be submitted to: NSA@Zelis.com
Please use secure email for PHI
Call Zelis at: 1-888-266-3053
Q1. When are Surprise Billing Protections applicable and for what scenarios?
Effective Jan. 1, 2022, UPMC Health Plan commercial members will be protected from balance billing after receiving emergency care and nonemergency care from certain out-of-network providers at in-network facilities. The No Surprises Act, which is included within the Consolidated Appropriations Act of 2021 (the CAA), provides the following:
- Bans surprise billing for emergency services: If a member receives emergency services, they will be covered at the in-network rate, and the services do not require prior authorization from UPMC Health Plan. This is true even if the services are received at a facility or from a provider that does not participate in their network. Additionally, members will be protected from balance billing when receiving post-stabilization services at a nonparticipating facility.
- Bans balance billing and out-of-network cost-sharing for emergency services as well as certain nonemergency services performed by a nonparticipating provider (or facility on behalf of the provider) at participating health care facilities including out-of-network ancillary providers such as pathologists, anesthesiologists, and radiologists at in-network facilities: In these situations, the member’s cost share cannot be higher than the cost share would have been if the services were provided by an in-network provider or an in-network facility. The member’s cost share must be based on the in-network rates.
- Bans balance billing for out-of-network air ambulance services.
Q2. How do I know Surprise Billing Protections have been applied to a claim?
Explanations of Payment (EOP) will include a remark that identifies the claim is a protected service to ensure required member/patient protections and provides contact information for any providers wishing to submit an Open Negotiation Notice.
EOP Sample text:
Priced at No Surprises Act QPA (Qualifying Payment Amount) Rates per July 2021 IFR – Balance Billing Prohibited. If provider disputes this payment, provider may submit Open Negotiation notice within 30 days. Federal IDR is available within 4 days after end of failed Open Negotiation.
Inquiries (please use secure email for PHI): email@example.com
Please refer to detailed submission information above
The following 2 codes will appear on the transaction:
N859 alert: The Federal No Surprises Billing Act was applied to the processing of this claim. Payment amounts are eligible for dispute following the Federal documented appeal/grievance/dispute resolution process.
N860 alert: The Federal No Surprises Billing Act Qualified Payment Amount (QPA) was used to calculate the member cost share(s).
Q3. How has member liability been calculated for services and claims covered by the No Surprises Act protections?
UPMC Health Plan will use the QPA to calculate member cost share for all out-of-network services protected by the No Surprises Act. Please see above for specifications of EOP and EDI indicators.
Q4. What is the QPA?
The Qualifying Payment Amount, or QPA, is the median of commercial contracted rates for similar services in a particular geographic area.
UPMC and its contracted extended networks are calculating the QPA rates per the July 2021 Interim Final Rule issued by “the Departments” (Department of Treasury, Department of Labor, Department of Health and Human Services).
Q5. When is the QPA used?
The QPA is used to calculate the member cost share for three protected scenarios under the No Surprises Act and protects members from exposure to potentially high out-of-network billed charges. These scenarios include:
- Out-of-Network Emergency Services
- Out-of-Network Air Ambulance Services
- Out-of-Network Providers at In-Network Facilities
The No Surprises Act creates specific negotiation and dispute processes that providers can pursue directly with payers and not involving the member/patient.
Q6. Where can I find the Open Negotiation Notice?
The Open Negotiation notice is available on the Department of Labor website.
Q7. Where can I find more information about the No Surprises Act and requirements of Providers?
No Surprises Act and Provider requirements can be found on the CMS website.