SENDINGA PATIENTSTATEMENTWHILEIN IDRPROCESS

If an All-Payer Model Agreement or specified state law does not apply cost sharing is determined based on the lesser of the billed charge or the Qualifying Payment Amount as calculated by the median contracted rate

When the recognized amount is the QPA, plans and issuers must provide the following information with an initial payment or notice of denial of payment:

(1) the QPA for each item or service involved;

(2) if the QPA is based on a downcoded service code or modifier, a statement from the plan or issuer explaining that the service code or modifier billed by the provider, facility, or provider or air ambulance services was downcoded; an explanation of why the claim was downcoded, including a description of which service codes or modifiers were altered, added, or removed, if any; and the amount that would have been the QPA had the service code or modifier not been downcoded;

(3) a statement to certify that the plan or issuer has determined that the QPA applies for the purposes of the recognized amount (or, in the case of air ambulance services, for calculating the participant?s, beneficiary?s, or enrollee?s cost sharing), and that each QPA was determined in compliance with the methodology established in the July 2021 interim final rules

(4) a statement that if the provider or facility, as applicable, wishes to initiate a 30- business-day open negotiation period for purposes of determining the amount of total payment, the provider or facility may contact the appropriate person or office to initiate open negotiation, and that if the 30-business-day open negotiation period does not result in a determination, generally, the provider or facility may initiate the Federal IDRprocess within 4 days after the end of the open negotiation period; and

(5) contact information, including a telephone number and email address, for the appropriate person or office to initiate open negotiations for purposes of determining an amount of payment (including cost sharing) for such item or service

The attached document includes the list of Remittance Advice Remark Codes which may be used by plans to communicate how cost sharing was calculated under the No Surprises Act. The other document helps determine the applicability for the Federal IDRprocess