Federal and State Surprise Billing Protections

Provider Arbitration pursuant to the Federal No Surprises Act

If this claim is subject to the Federal No Surprises Act, the paid amount is the lesser of billed charges or the qualifying payment amount for this item or service, which is calculated in accordance with the No Surprises Act and implementing regulations. The qualifying payment amount also applies for purposes of the recognized amount (or, in the case of air ambulance services, for calculating the participant's, beneficiary's, or enrollee's cost sharing). You may contact ClearHealth at 1-866-722-3773 or [email protected], to initiate a 30-business-day open negotiation period. If the 30-business-day open negotiation period does not result in an agreement on the out-of-network rate, you may initiate the Federal IDR process within 4 business days of the end of the open negotiation period. Payments are made in compliance with the Federal No Surprises Act or applicable state law. The member is not responsible and cannot be balance billed for covered out of network services beyond allowed amount.

Provider Disputes pursuant to Texas State Law

Texas state law authorizes arbitration (for doctors) and mediation (for facilities) to resolve payment disputes for emergency care, care provided at in-network facilities when the patient didn’t have a choice of doctors, and for certain lab and imaging services associated with in-network care. If this claim is subject to Texas state law and you disagree with the payment amount, you can initiate a negotiation with ClearHealth at [email protected] or initiate mediation or arbitration. To learn more about IDR and the associated timelines or to submit a request, go to www.tdi.texas.gov. After you submit a complete request, you must notify ClearHealth at [email protected].

*Texas air ambulance providers should follow the directions under “Provider Disputes pursuant to the Federal No Surprises Act.”

 

 

Resources

Notice for Requesting Open Negotiation (submit form included on page 3 & 4 to ClearHealth)

Notice for IDR Initiation

 

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