Provider Notice/FAQs: Federal No Surprises Act

Effective January 1, 2022, the No Surprises Act protects patients from receiving surprise medical bills from non-participating providers, including for emergency and air ambulance services. Below is a list of frequently asked questions (FAQ) about the No Surprises Act. For more information related to the No Surprises Act, visit the CMS Provider Requirements and Resources web page.

1. When does the No Surprises Act go into effect?

The No Surprises Act’s (NSA) protections against surprise medical bills went into effect on January 1, 2022.

2. How does the No Surprises Act protect 1199SEIU members?

Members are protected from balance billing when a member receives: (a) emergency services from a non-participating provider or facility, (b) certain non-emergency services from a non-participating provider at an in-network hospital or ambulatory surgical center, or (c) air ambulance services from a non-participating provider. Non-participating providers who seek payment above the Benefit Funds’ reimbursement amount for services subject to the No Surprises Act’s protections may not bill patients for the balance between their billed charges and the Benefit Funds’ reimbursement amount. Instead, providers may initiate an open negotiation period with the Benefit Funds, and they may ultimately seek to resolve the matter through the Independent Dispute Resolution (IDR) process.

3. What types of services are considered emergency services?

Emergency services generally refer to the following hospital services used to treat emergency medical conditions:

• Appropriate medical screening examinations and stabilization services as required under the Emergency Medical Treatment and Labor Act (EMTALA) within the capability of the emergency department of a hospital.
• Additional “post-stabilization” benefits furnished by an out-of-network provider or emergency facility (regardless of the department of the hospital where the items/services are furnished) after the member is stabilized. These are subject to surprise billing protections unless certain conditions are met, including the following:
• The member is stable enough to travel using non-medical or non-emergency medical transport to an available in-network provider/facility located within a reasonable travel distance given the individual’s medical condition;
• The member or an authorized representative is in a condition where he or she can receive information and provide informed consent; and
• The provider/facility provides written notice and obtains written consent from the member to waive balance billing protections, in compliance with all related statutory and regulatory requirements.

Emergency medical conditions are illnesses, injuries, symptoms or conditions—including those related to behavioral health/substance use disorders—that are so serious that reasonable persons would seek medical care immediately to avoid severe harm to themselves or their unborn child.

4. What services are non-participating providers prohibited from balance billing members under the No Surprises Act?

• Emergency services provided at a non-participating hospital or by a non-participating provider or air ambulance provider.
• Non-emergency “ancillary services” furnished by a non-participating provider at an in-network facility. “Ancillary services” are defined by the No Surprises Act and include those related to emergency medicine, anesthesiology, pathology, radiology, neonatology and laboratory tests, as well as in situations where a participating provider is not available at the in-network facility to provide the services. A non-participating provider at an in-network facility may balance bill a member if the provider is not furnishing ancillary services and gives advance notice to the member that the covered item or service is out of network and provides the estimated cost; the member must acknowledge that he or she has received the notice.

5. What other requirements must providers follow under the No Surprises Act?

• Ensure accuracy of their demographic information for provider directories. Our members often rely on the information in our online provider directory when seeking healthcare services. If you have any updates to your demographic information—such as changes in service locations and billing information, phone numbers, or affiliations—please fill out a Provider Demographic Information Change Request Form and submit it to the Benefit Funds. It is important that we have the most up-to-date information available, as we will remove from our provider directory any providers whose information we are unable to verify.
• Disclose patient protections against balance billing and how to report violations. Providers or facilities must post this information prominently at their facilities and on a public website (if applicable) and provide it to patients as outlined in No Surprises Act regulations.
• Provide patient protections related to continuity of care. When a participating provider leaves the Benefit Funds’ network, the provider must generally continue care for up to 90 days after the patient is notified of the change in participation status if the patient is: (a) receiving treatment for a serious and complex condition; (b) undergoing a course of institutional or inpatient care; (c) scheduled for non-elective surgery, including post-operative care; or (d) receiving a course of treatment for pregnancy or a terminal illness.

6. If a non-participating provider did not receive notice of the Benefit Funds’ qualifying payment amount on a claim he or she believes is subject to the NSA, how can he or she request that information?

A non-participating provider may request a duplicate notice by calling our Provider Relations Call Center at (646) 473-7160 or emailing [email protected].

7. May non-participating providers dispute the Benefit Funds’ initial payment?

Yes. Under the No Surprises Act, if a non-participating provider does not accept the Benefit Funds’ initial payment and wants to initiate an Open Negotiation, he or she has 30 business days after receiving the initial claim payment or denial to complete the Open Negotiation request form (PDF) and email it to [email protected].

8. How does a non-participating provider initiate the Independent Dispute Resolution process?

If the Benefit Funds and a non-participating provider do not reach an agreement by the end of the Open Negotiation period, the non-participating provider may initiate the federal Independent Dispute Resolution (IDR) process for eligible claims within four business days of the end of the Open Negotiation period by completing the Federal IDR initiation form (PDF) and emailing it to [email protected] .

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