An out-of-network provider or facility that treats a patient for emergency services or cares for a patient at an in-network hospital for scheduled services will submit a claim to the patient’s health plan.
The amount the health insurer pays the out-of-network facility or provider must be a “commercially reasonable amount” based on the same services in a similar geographic area. If the health plan and the facility or provider cannot agree on the amount, either party can start arbitration.
Learn more about the Balance Billing Protection Act dispute resolution process.
The law also requires health insurers to have a way to let an out-of-network provider or facility know whether the health care service(s) they provided are subject to the Balance Billing Protection Act. Health insurers must also let providers and facilities know who to send an arbitration request to.
How arbitration works
If the insurer and provider or facility cannot agree on a price for the service, either party can start arbitration. The law requires that health insurers provide OneHealthPort with the email address and phone number of the insurer's designated contact to receive notices to start arbitration. Send the information to:
Each party pays their own attorney fees, and they split the cost of arbitration. The arbitrator will choose the best final offer from one party.
Parties will have access to a data set from the All Payer Claims Database that:
- Is based on commercial fee-for-service health insurance claims.
- Includes median in-network, out-of-network and billed charges for services covered under the Act.
See a list of approved arbitrators.
What information insurers must share with enrollees
Insurers must post the notice of consumers’ surprise billing rights on their website and update their online provider directory within 30 days when a provider is added or terminated. Also, they must give enrollees:
- A clear description of the health plan's out-of-network benefits.
- If asked, an estimated range of out-of-pocket costs for an out-of-network service.
- What an enrollee's financial responsibility is if they get out-of-network services other than those protected from balance billing.
See the notice for consumers about their rights (PDF, 114KB) under the Balance Billing Protection Act.