Surprise Billing Notice Disclosure

When services on a claim are out-of-network per the covered individual’s contract, state and/or federal laws may protect the covered individual from your balance (surprise) billing of this claim.

STATE: Nebraska State law requires that certain out-of-network services be paid at in-network rates without regard to the covered individual’s contract. 

Effective Jan. 1, 2020, providers in Nebraska may no longer balance bill Blue Cross and Blue Shield of Nebraska covered individuals for medical care received from out-of-network providers or facilities in emergency situations. The Nebraska Out-of-Network Emergency Medical Care Act (LB997) protects consumers from getting surprise bills from out-of-network providers or facilities for emergency medical services. Facilities are defined as a general acute hospital, satellite emergency department or ambulatory surgical center licensed pursuant to the Health Care Facility Licensure Act.  This state mandate applies to all individual policies, fully insured group health plans and non-ERISA self-funded groups.

FEDERAL: The No Surprises Act (as part of the 2021 Consolidated Appropriations Act) requires that certain out-of-network services be paid at in-network rates without regard to the covered individual’s contract, and further require that a Qualifying Payment Amount (QPA)* be used to determine the covered individual’s cost-share responsibility. Your total payment (BCBSNE reimbursement plus member cost-sharing) will not change based upon the QPA amount determined.

Effective Jan. 1, 2022, providers in Nebraska may no longer balance bill Blue Cross and Blue Shield of Nebraska covered individuals (pursuant to their Plan Year start date) for medical care received from out-of-network providers or facilities in emergency situations (to include emergency and related post-stabilization services), nonemergency services provided by a nonparticipating provider in a participating facility, and air ambulance services. The No Surprises Act protects consumers from getting surprise bills from out-of-network providers or facilities for these services. This federal mandate applies to all individual policies, fully insured group health plans and both ERISA and non-ERISA self-funded groups where the state law does not apply.

* Based on the determination of Blue Cross and Blue Shield of Nebraska:
(1) The QPA applies for purposes of the recognized amount for member cost-sharing liability, and 
(2) Each QPA was determined in compliance with the methodology outlined in the interim final rules.
(3) With respect to air ambulance services, the QPA, rather than the recognized amount, applies for purposes of calculating the member’s cost-sharing liability.

However, the lower of the billed charge or rate negotiated under a separate network contract will be used for member cost-sharing liability when either (or both) is lower than the recognized amount (or for air ambulance, the QPA).  NOTE: the member cost-share amount does not impact the total amount paid to the provider.

If you disagree with the total payment or the QPA (if applicable):

According to LB997, Nebraska Out-of-Network Emergency Medical Care Act, you may:

  • Notify us via LB997 - Out of Network Emergency Medical Care Act – Reimbursement Dispute Request
    • Include a return check in the amount BCBSNE paid for the service you are disputing (no return check is necessary for dispute of a denied payment for service)
    • Send the form and check to Blue Cross and Blue Shield of Nebraska, PO Box 30112, Omaha, NE 68103-1212
  • Negotiation between you and BCBSNE may continue for 30 days
  • If a settlement cannot be reached within the 30-day window, either party may pursue mediation in accordance with the Uniform Mediation Act

According to the No Surprises Act (as part of the 2021 Consolidated Appropriations Act), you may:

  • Provide completed Open Negotiation Notice (dol.gov) in an email addressed to BCBSNE at ProviderExecs@NebraskaBlue.com within 30 business days from the date you receive initial payment or notice of denial
  • Negotiation between you and BCBSNE may continue for 30 business days
  • If this negotiation does not result in an agreed upon determination within 30 business days, you may further initiate arbitration via the Independent Dispute Resolution process within the four business days subsequent to the end of this 30-day negotiation period