No Surprises Act Payment Disputes

The No Surprises Act (NSA) is a U.S. federal law that went into effect on January 1, 2022, designed to protect patients from unexpected medical bills—also known as “surprise billing”—in situations where patients receive emergency services from out-of-network providers or from an out-of-network provider delivering care at an in-network facility. However, the federal NSA process is not applicable in certain circumstances.

Not Eligible for the Federal NSA Process:

The Surprise Billing and Transparency Requirements establish standards for group health plans and health insurance issuers offering group or individual coverage. The federal Independent Dispute Resolution (IDR) process does not apply to state regulated insurance plans that have an active law that governs surprise billing or items and services payable by those agencies noted below:

• State-Regulated Insurance Plans
  Per Nev. Rev. Stat. § 439B.748, out-of-network facilities and providers who render emergency care within the state of Nevada to a member whose health insurance is issued by a state-regulated insurance carrier are not eligible for the federal Independent Dispute Resolution (IDR) process—unless the services were rendered outside the state of Nevada.

• • You can identify state regulated plans if the EOP reflects:

• • • • Hometown Health Plan (HMO)
      • Hometown Health Providers (PPO)

• Nevada Department of Corrections (NDOC)
  Inmates under the custody of the Nevada Department of Corrections (NDOC) are not eligible for the federal IDR process because they are not covered under a group or individual health plan, as required by the No Surprises Act. Please refer to 45 CFR 149.20 for applicability. NDOC oversees the delivery of legally required medical care to inmates, and Hometown Health processes claims for services received from external providers. However, because these individuals are not enrolled in a health plan administered or issued by Hometown Health, their claims are not eligible for the IDR process.

•  Medicare Advantage Plans
  • Members enrolled in Hometown Health’s Senior Care Plus product are Medicare beneficiaries enrolled in a Medicare Advantage plan.

• • Medicaid Plans
  • TRICARE (Treatment, Resources, and Insurance for Active-Duty and Retired Military Personnel and Caregivers)
  • Children’s Health Insurance Program (CHIP)

Please reference the appeal and dispute procedures for non-contracted providers here: NSA Disputes, Appeals, and Reconsiderations.

Eligible for the Federal IDR Process:

• Any air ambulance service provided to a member on the date of service, excluding Senior Care Plus and NDOC members.
• TPA plans that have not opted in to be covered under Nev. Rev. Stat. § 439B.748 for emergency services provided by out-of-network facilities and providers.

* Note: Individuals covered under Senior Care Plus (Medicare Advantage) and NDOC members are not eligible under the NSA.

How to Submit for the Federal NSA Process

The federal NSA process requires plans and providers to engage in Open Negotiations within 30 business days of receiving the Explanation of Payment (EOP). All requests for Open Negotiation must be sent to NSAproviderdispute@hometownhealth.com. Requests received after the 30-day period will be dismissed and deemed ineligible for the federal IDR process.

For No Surprises Act payment disputes relating to Air Ambulance, out of network Emergency Services, or an out of network provider servicing a member at an in-network facility, you may initiate the open negotiation process or submit an IDR initiation notice to NSAproviderdispute@hometownhealth.com

You can also contact Customer Service at 775-982-3232.