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Steps to Comply with the No Surprises Act

April 29, 2022 1123

In an effort to protect individuals from receiving surprise medical bills and to further the need for transparency around health care costs, the No Surprises Act was signed into law and became effective January 1, 2022, as part of the Consolidated Appropriations Act of 2021 (H.R. 133; Division BB – Private Health Insurance and Public Health Provisions). Similar to California Law AB 72 (which excluded dental), The No Surprises Act protects patients at a federal level from receiving balance bills when being treated by an out of network provider in an in-network facility.

There are 4 main components of the No Surprises Act, Balance Billing, Notification of Rights, Good Faith Estimate and Dispute Resolution Process.

The Balance Billing component of the law prohibits an out of network provider to bill a patient for services received at an in-network facility. According to the law, hospitals ambulatory surgical centers, rural health centers and federally qualified health centers are examples of covered facilities in the balance billing requirement. Private dental practices are not included in the definition of covered facilities; however, a dental provider performing treatment at a covered facility may have additional obligations under the law.

The remaining 3 components of the No Surprises Act, Notification of Rights, requirement to provide a Good Faith Estimate and the Dispute Resolution Process do apply to private dental practices. Below are the steps dental providers need to take in order to comply with the No Surprises Act.

POST

Information regarding the availability of a “Good Faith Estimate” must be prominently displayed in the office and on-site where scheduling or questions about the cost of health care items or services occur.

A sample notice considered by the Health and Human Services to be in compliance with the requirement informing patients of their right to receive a Good Faith Estimate, is included at the end of this resource.

INFORM

The No Surprises Act requires uninsured (self-pay) patients, or individuals choosing to not have claims submitted to their plan, to be informed of their rights under the No Surprises Act. This includes the right to receive a Good Faith Estimate, noting their rights should they receive a bill in excess of $400.00 more than the initial Good Faith Estimate and the information where they can dispute the bill.

PROVIDE

A Good Faith Estimate must be provided within specified timeframes (see timeline below), in writing either on paper or electronically (and may also be provided orally if requested by the individual). When providing a Good Faith Estimate electronically, you must ensure patients health information remains protected. For example, if you are sending the Good Faith Estimate via email be sure the email is encrypted.

Good Faith Estimates MUST contain:

  • Name and Date of Birth of the patient
  • A description of the primary service in clear understandable language (e.g.: porcelain fused to high noble metal crown)
  • An itemized list of items and services reasonably expected to be performed (e.g.: crown and build up)
  • Service codes (Current Dental Terminology codes)
  • Diagnosis code (International Classification of Diseases codes)
  • Expected charges associated with each item
  • Name of treating provider
  • Physical location of office
  • TIN or EIN
  • NPI
  • List of items requiring separate scheduling (if applicable)
    • For example:
      • Root canal procedure needing to be scheduled prior to a crown procedure
      • Crown lengthening procedure needing to be schedule prior to a crown procedure
      • Diagnostic imaging needed prior to implant placement
      • Post operative dressing change for which the patient will be charged
  • Disclaimers stating
    • Estimate is subject to change
    • Additional items or services are not contained in estimate
    • Patients’ rights to initiate a dispute resolution process
    • Good Faith Estimate is not a contract to provide services

Can the Good Faith Estimate be automated by my practice management software?

Offices currently using practice management software to provide patients with financial agreements or financial estimates must ensure ALL the above elements of the Good Faith Estimate are included on financial documents for uninsured (self-pay) patients, or individuals choosing to not have claims submitted to their plan. Contact your practice management software provider to inquire if the financial forms are compliant or may be edited to add/include the above required elements. You may also provide uninsured (self-pay) patients, or individuals choosing to not have claims submitted to their plan with a customized version of the sample Good Faith Estimate and disclosures included at the end of this resource.

When does the estimate need to be provided to the patient?

When an item or service(s) is scheduled at least three business days before the date the item or service(s) is provided, a Good Faith Estimate must be given no later than one business day after scheduling. When an item or service(s) is scheduled at least ten business days before the item or service(s) is provided, a Good Faith Estimate must be given no later than three business days after scheduling. A Good Faith Estimate must be provided within three days upon request.

Good Faith Estimate Timeline

# of Days to Appointment

Estimate must be provided

Upon Request

Within 3 business days

3-9 days

No later than 1 business day after scheduled

10+ days

No later than 3 business days after scheduled

For complete and current information on the No Surprises Act visit HHS interim final rules (IFR) titled Requirements Related to Surprise Billing; Part II, published on October 7, 2021

Disclaimer

This Good Faith Estimate is valid for a period of 12 months from the date on the estimate. The Good Faith Estimate shows the costs of items and services that a patient could reasonably expect for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created, could be subject to change, and is not a contract.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that provider or facility, federal law allows you to dispute the bill.

If you are billed for more than this Good Faith Estimate, you may have the right to dispute the bill.

You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

You may 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.

If you dispute your bill, the provider or facility cannot move the bill for the disputed item or service into collections or threaten to do so, or if the bill has already moved into collection, the provider or facility has to cease collection efforts. The provider or facility must also suspend the accrual of any late fees on unpaid bill amounts until after the dispute resolution process has concluded. The provider or facility cannot take or threaten to take any retributive action against you for disputing your bill.

There is a $25 fee to use the dispute process. If the Selected Dispute Resolution (SDR) entity reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate, reduced by the $25 fee. If the SDR entity disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises/consumers or call 1-800-985-3059.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers and email [email protected], or call 1-800-985-3059.

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to: (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entity’s compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.

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