No Surprises Act of 2021: Out-of-Network Payment Disputes


Ending Surprise Medical Bills

The No Surprises Act of 2021 provides federal protections for patients against surprise billing and balance billing for certain services. Out-of-network providers are generally prohibited from balance billing Commercial and Tufts Health Direct members for the following services:

  • Out-of-network emergency care
  • Certain non-emergent services by out-of-network providers during visits to in-network facilities
  • Out-of-network air ambulance services

Visit CMS’ website for more information.

Open Negotiation Process

Out-of-network claims that qualify for No Surprises Act protections are priced by Tufts Health Plan at the Qualified Payment Amount (QPA). Out-of-network providers who disagree with the QPA may initiate a 30-business-day open negotiation process by contacting Zelis, our delegate for pricing out-of-network claims:

Independent Dispute Resolution

If an agreement cannot be reached through the open negotiation process, the out-of-network provider may request an Independent Dispute Resolution (IDR) through the CMS website within 4 business days.