Ambetter Surprise Billing Provider Notice

Date: 08/11/21

Ambetter from MHS HEA 1447 Surprise Billing and Good Faith Estimate Process Effective Date Changed to January 1, 2022

As part of the 2021 Indiana General Assembly Session, the effective date for surprise billing and good faith estimates was moved back to January 1, 2022 from July 1, 2021. Additional changes include clarifying that the member must receive a good faith estimate within 5 business days before the service and updating requirements around member notices. Please see Ambetter’s original post from March 2021 with edits from HEA 1447 underlined for additional information:

From March 2021:

Ambetter from MHS HEA 1004 Surprise Billing and Good Faith Estimate Process

Surprise or balance bills can occur when an out-of-network health care provider bills a patient directly for the portion of their charges that exceed the fair and reasonable rate. In 2020, House Enrolled Act (HEA) 1004 amended IC 25-1-9-23 to outline requirments in regard to balance billing. Ambetter from MHS is taking action to implement requirments for members who receive care from out of network providers who provide services at a participating hospital. Effective 1/1/2022, it is important for non-participating providers who intend to render services at an in-network facility to follow the requirments of notifying the covered member, at least 5 business days before a service is rendered, with a good faith estimate if the provider intends to charge the member above the established fee schedule.

Key Provisions of HEA 1004

Detailed requirments are outlined in the Indiana code SECTION 6, IC 25-1-9-23, of HEA 1004.

In-Network Providers

• Providers participating with Ambetter my not charge more than the network fee schedule other than member responsibility including copay, coinsurance and deductible.

Out of Network Providers

• Providers who are not participating with Ambetter who render services at an in-network facility will be reimbursed at the network fee schedule for non-participating providers.
• Out of network providers may charge members for member responsibility including copay, coinsurance and deductible.
• Other than member responsibility, members may not be charged more than the following;
  • If Ambetter reimburses the service at the out of network fee schedule, the member may not be additionally charged.
  • If Ambetter partially reimburses or denies reimbursement, the member may only be charged up to the out of network fee schedule.
  • If the out of network provider intends to charge either $100 or 5% above the established out of network fee schedule, at least 5 business days before the service the provider must give the member a specific form in conspicuous font with the following information:
    • A statement that the provider intends to charge more than the network fee schedule;
    • A “good faith” estimate of the services to be charged;
    • A place to sign and date the statement consenting to the additional charges.
      • The member’s signature must be on the form as the act of giving the member the statement is not sufficient.

Ambetter from MHS Processes

• If a provider intends to bill above the out of network fee schedule, please call Ambetter at 1-877-687-1182 to initiate a request for the out of network fee schedule for services being rendered.
• Ambetter will provide the information as requested by the provider not more than two (2) business days after receiving the request as required by HEA 1004.

If you have questions, please contact Ambetter at 1-877-687-1182.

Thank you for being our partner in care.