Balance billing

The No Surprises Act protects people covered under group and individual health plans from surprise billing or balance billing when they receive:

• Emergency services
• Non-emergency services from out-of-network providers at in-network facilities
• Services from out-of-network air ambulance service providers

Balance billing, also known as surprise billing, is an unexpected balance bill. This can happen when you can’t control who’s involved in your care — like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

When you see a doctor or other healthcare provider, you might owe certain out-of-pocket costs, like a copay, coinsurance and/or a deductible. You can have other costs or must pay the entire bill if you see a provider or visit a healthcare facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers can be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service (balance billing). This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

If you believe you’ve been wrongly billed, call 800-985-3059. Visit cms.gov/nosurprises for more information about your rights under federal law.

Providers who believe payment for services qualify for the Open Negotiation Period (ONP) under the No Surprises Act and would like to initiate the ONP should use the form provided at the link below.

Open Negotiation Period Form

Broker compensation

The law also requires health plans to share information on processes that can affect your healthcare coverage costs.

Geisinger Health Plan pays agent or brokers for enrolling members into individual plans. The No Surprises Act requires Geisinger Health Plan to disclose agent or broker compensation.

Read No Surprises Act FAQs

Machine-readable files 

In late 2020, the No Surprises Act was signed into law to support protecting patients from surprise medical bills. As part of this law, Transparency in Coverage rules (the TiC Final Rules) were established. This requires non-grandfathered group health plans and issuers offering non-grandfathered coverage in the group and individual markets to disclose information regarding:

1. In-network rates for covered items and services
2. Out-of-network allowed amounts and billed charges 

This data must be made publicly available by July 1, 2022, in two machine-readable files (MRFs) for plan years beginning on or after January 1, 2022.  

Machine-readable files

•  Table of contents

Fully Insured Employer Groups

• The Transparency In Coverage rules states that it is the responsibility of Geisinger Health Plan (GHP) to provide and make available information related to Machine Readable Files. Since the fully-insured employer group purchased insurance coverage from Geisinger Health Plan, it is GHP’s responsibility to make this information available. As such employers purchasing, or who have purchased, Geisinger Health Plan fully insured group health coverage can rely on Geisinger Health Plan to make information related to Machine Readable Files publicly accessible when available.

Self-Insured Employer Groups

•  In self-insured arrangements, the Transparency In Coverage rules requires plan sponsors or employers to make Machine Readable Files available. However, Geisinger Indemnity Insurance Company is committed to delivering the highest level of services to its customers and will provide and update machine readable files for self-funded employer groups. Such groups may also share the URL link on their website, if they choose.

MRF assumptions and disclaimers

• Data is accurate as of the date it is pulled from our system. Geisinger Health Plan does not guarantee the accuracy of the data between the date it is pulled and the next update. 
• Geisinger Health Plan shall not be held responsible for the use or interpretation of data by any third parties.
• Users accept the data quality as is, are responsible for becoming familiar with any limitations in data documents and are responsible for identifying information that meets their needs.  
• Geisinger and its affiliates are not responsible for any changes, conversions, manipulations or reprocessing made to the original data.  
• Users shall not refer to or present any altered original data as Geisinger Health Plan data. 
• Data provided requires sizeable files that may result in slower-than-usual download times.  

Prescription Drug Data Collection and Reporting Information

As part of the Consolidated Appropriation Act of 2021, insurance companies and employer-based health plans are required to submit information about prescription drug and healthcare spending to the Departments of Health and Human Services, Labor and Treasury. Submissions are due June 1 of every year. At Geisinger Health Plan (GHP), we’re committed to helping our customers fulfill these requirements.

Geisinger’s deadline to submit the RxDC reporting is June 1, 2024. Failure to provide employer-specific information by Friday, April 12, will result in an incomplete submission and non-compliance with the RxDC reporting requirement. You and your groups can use the link below to fill out a form applicable for each line of business and funding arrangement.
 
Questions? Contact your account executive.

Gag Clause Reporting

More information about Gag Clause Reporting can be found here.

NSA Gag Clause Attestation

No Surprises Act FAQs

Get answers to our most frequently asked questions about the No Surprises Act: 

What’s a Good Faith Estimate?

Federal Register requires providers and facilities to furnish a good faith estimate that shows the costs of items and services that are reasonably expected for your healthcare needs.

The estimate is based on information known at the time the estimate was created. The Good Faith Estimate doesn’t include any unknown or unexpected costs that can arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. You can contact the healthcare provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate you received. You can:

• Ask them to update the bill to match the Good Faith Estimate
• Negotiate the bill
• Ask if financial assistance is available

Can I dispute an unexpected bill balance?

Yes. You can also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. 

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you’ll have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you’ll have to pay the higher amount. 

To learn more and get a form to start the process, go to cms.gov/nosurprises or call 800-985-3059. 

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit cms.gov/nosurprises or call 800-985-3059.

Keep a copy of your Good Faith Estimate in a safe place or take pictures of it. You might need it if you’re billed a higher amount.

What services cannot balance bill?

The following services cannot balance bill and don’t need prior authorization to be covered under the act:

• Anesthesiologists
• Any service provided by an out-of-network provider if no in-network provider was available at the facility
• Assistant surgeons
• Diagnostic services like radiology and laboratory* 
• Emergency room providers
• Hospitalists
• Intensivists
• Neonatologists
• Other specialty items or services as identified by HHS
• Pathologists
• Radiologists
• Urgent services that arise during a service for which Notice and Consent was provided

*Advanced diagnostic laboratory tests are not included 
Source: Pennsylvania Insurance Department

What is a Notice and Consent form?

A Notice and Consent form is a document that must explain:

• That the provider doesn’t participate with the patient's healthcare plan.
• The good faith estimated amount the provider may charge the patient for all services that would reasonably be included.
• That the service might need to be authorized or otherwise approved by the patient’s health plan.
• That signing the notice is optional and that a patient doesn’t have to consent.
• That the patient may get the service from an available in-network provider.

This document must be separate from any other forms and should be very clear and easy to understand. You should only sign one of these forms if you want to see a particular provider for a medical service and if you fully understand the form. 

This form must be provided at least 72 hours (three days) before a medical service is finished. If a service is scheduled within three days, the notice must be given at least three hours ahead of time. You have the right to revoke a Notice and Consent form before a service is provided.

Source: Pennsylvania Insurance Department 

Learn about No Surprises Act protection

Read about how the No Surprises Act protects consumers who receive coverage through their employer (including a federal, state or local government), through the Health Insurance Marketplace or directly through an individual health plan, beginning January 2022: