How out-of-network claims get priced
Order of precedence: a direct contract or pre-negotiated rate first, then the network or repricer if the plan has one, then the plan's maximum allowable
The maximum allowable is defined in the plan's SPD and is typically 150% to 225% of Medicare
Related: Direct Contracts, Claim Reimbursements, Payer ID and real-time status
What RBP is
Reference-Based Pricing: the allowed amount is a Medicare-based multiple instead of a network-negotiated rate
The RBP calculator in the portal sidebar estimates the allowed amount for most services
Related: Comparing costs to RBP
What the member owes above the allowance
Charges above the maximum allowable are the member's responsibility and do not count toward the out-of-pocket maximum
Related: Out of Pocket Costs
No Surprises Act protections
The NSA protects members from balance billing for emergency services, ancillary care at in-network facilities, and air ambulance
Cost-sharing is based on the QPA (the median contracted rate), not the provider's billed charge
Related: No Surprises Act Disputes
What to do about a balance bill
If a member receives a balance bill, route it through Patient-Provider Disputes or NSA Disputes
Related: Patient-Provider Disputes