Implement the No Surprises Act balance billing protections for out-of-network emergency services: detect applicable claims and apply the correct payment calculation

Verified steps

1. Identify claims that meet the definition of a covered emergency service rendered by a nonparticipating provider at an in-network emergency facility — these claims fall under the No Surprises Act balance billing prohibition.
2. Calculate the qualifying payment amount (QPA) for each claim: the QPA is generally the plan's median contracted rate for the same or similar service in the same geographic area, determined as of January 31, 2019, and indexed annually.
3. Apply the greater of three potential payment floor options as required: the QPA, the plan's usual out-of-network amount, or the amount that would be paid under Medicare fee-for-service — this ensures the patient is not balance billed beyond cost-sharing based on the applicable floor.
4. Notify the provider of the initial payment or denial with an explanation, informing them of the QPA and their right to initiate open negotiation within 30 business days.
5. Send the patient an Explanation of Benefits that reflects the cost-sharing based on in-network rates (not out-of-network rates), with a notice that balance billing above the cost-sharing amount is prohibited for this service.
6. Maintain documentation of the QPA calculation methodology and data source for each service type and geographic area in the event of an IDR challenge.