Regulatory Updates
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Departments Issue FAQs Part 62 Regarding Implementation of the No Surprises Act Following Court Decision Vacating Some Guidance
Oct 6, 2023, 05:00
by
Tyler Lloyd
The Departments of Labor (DOL), Health and Human Services (HHS),
and the Treasury (collectively, the Departments) have jointly prepared FAQs Part 62 in
light of the August 24, 2023, court order vacating certain provisions
of the July 2021 interim final rules certain portions of No Surprises
Act guidance documents issued by the Departments in the case of Texas Medical Association et al. v. United States Department of Health and Human Services et al., (TMA III).
The district court’s decision is currently in effect. The Department of Justice intends to appeal.
Of relevance to these FAQs, the decision in TMA III vacated the following provisions:
- Some provisions related to the qualifying payment amount (QPA) methodology, including the inclusion of contracted rates for items and services “regardless of the number of claims paid at that contracted rate,” the use of contracted rates of all self-insured group health plans administered by the same entity, rules governing calculation of the QPA for providers “in the same or similar specialty,” the exclusion of bonus, incentive, and risk-sharing payments, and the exclusion of single case agreements.
- The provision starting the 30-calendar-day timeframe for a plan or issuer to send an initial payment or notice of denial of payment for air ambulance services when the plan or issuer receives the information necessary to decide a claim for payment.
In light of the decision in TMA III, the seven FAQs address the following topics:
- How should plans and issuers calculate a QPA for purposes of patient cost sharing
- Disclosures with an initial payment or notice of denial of payment disclosures and submissions required under the Federal Independent Dispute Resolution (IDR) process
- Methodology for calculating a QPA
- Disclosures about the QPA with an initial payment or notice of denial of payment, disclosures about the QPA in a timely manner upon request of the provider or facility
- How certified IDR entities proceed in considering a QPA submitted to a Federal IDR payment dispute
- Air ambulance services