Wiki No Surprise Billing Act

[lindam@caricures.com]

I started seeing "N860 Alert: The Federal No Surprise Billing Act QPA calculate member cost" on EOB's. Can anyone explain this to me. Thanks.

 

[CBLENNIE]

I'm guessing you are seeing this RARC on claims where your provider(s) are out-of-network (OON) with the patient's plan.

If you are an out-of-network provider, the allowed amount is based on the recognized amount using the methodology outlined in the interim final rules of the Consolidated Appropriations Act (i.e., lesser of billed charges and the Qualifying Payment Amount [QPA]). For emergency services, emergency post stabilization, and non-emergency services, the member’s cost share is calculated against the recognized amount, and for air ambulance services, the member cost share is calculated against the lesser of the Qualifying Payment Amount or the billed amount.

The QPA is defined in regulation and is generally the plan or issuer’s median contracted rate for the item or service in the geographic area where the item or service was delivered from January 31, 2019, indexed for inflation.