AZ Blue QPA Disclosure Statement

Related Services Code List (2022-2023) used to determine QPA

Claim pricing and member cost share
For claims in-scope for the NSA protections, AZ Blue prices claims in compliance with the NSA. In Arizona, the NSA-recognized amount is the qualifying payment amount (QPA), and is determined according to a specific formula from the federal government. AZ Blue bases member cost share on the lesser of QPA or billed charges.

Right to request open negotiation
Out-of-network providers have the right, within 30 business days from the date of the claim payment, to ask for open negotiation about the initial payment amount, using one of the following negotiation request forms:

• AZ Blue form (This complies with the U.S. Department of Labor form, includes information we need to identify your claim, and is fillable for your convenience.)
• Department of Labor info/form (If you use this form, you must also send the information required on the AZ Blue form, including the patient name, member ID, and claim number.)

You may send your completed request form, along with a copy of your remit, to our negotiation team at NSArequest@azblue.com.

The “No Surprises Act” (NSA) is part of the federal Consolidated Appropriations Act (CAA) signed into law in 2020. The NSA includes patient billing protections effective January 1, 2022.

For plan and policy years starting on and after January 1, 2022 (and on 2022 renewal dates for existing clients), AZ Blue will follow the requirements of the NSA in reimbursing out-of-network providers for emergency, air ambulance, and other professional services that are in-scope for the NSA.

• For in-scope claims, we will calculate member cost share using the in-network level of benefits and based on the qualifying payment amount (QPA), which is determined according to a formula specified in federal rules.
• In most cases, the initial payment to the out-of-network provider will also be based on the QPA, less the member cost-share amount. Providers have the right to dispute the initial payment amount. For more information, see below.

Within 30 business days of receiving a claim payment, out-of-network providers may request open negotiation to dispute the initial payment for commercial and Federal Employee Program® (FEP®) claims in-scope for the NSA.

In-scope NSA services include the following out-of-network services:

• Emergency services
• Air ambulance services
• Non-emergency professional and ancillary services rendered in an in-network facility

The disputes are resolved through the NSA negotiation/arbitration process, which includes a 30-business-day open-negotiation period between the provider and the payer. The parties attempt to negotiate a resolution. If they can’t agree within the 30-day time frame, the dispute may be referred to a certified independent federal arbitrator.

To the extent that AZ Blue is required by A.R.S. § 20-3102(F) to have a process for resolving payment disputes, AZ Blue has adopted the NSA process for all claims considered in-scope for the NSA. In this type of dispute scenario, the NSA negotiation/arbitration process replaces the AZ Blue provider grievance process for disputing the claim payment amount.

For more information, you can visit the federal NSA resource page.

An out-of-network provider may initiate the open-negotiation period by submitting the NSA Claim Payment Negotiation Request form to us at NSArequest@azblue.com, along with a copy of the remit statement:

• AZ Blue Negotiation Request form (This complies with the U.S. Department of Labor form, includes information we need to identify your claim, and is fillable for your convenience.)
• Department of Labor info/form (If you use this form, you must also send the information required on the AZ Blue form, including the patient name, member ID, and claim number.)

AZ Blue contact information for independent dispute resolution (IDR) submission

AZ Blue
P.O. Box 13466
Phoenix, AZ 85002

NSArequest@azblue.com
1-800-232-2345 Ext. 4231

In certain rare circumstances, patient notice and consent to waive billing protections may be applicable:

• When post-stabilization services are provided after an ER visit (must meet specific criteria)
• When out-of-network services are provided in an in-network facility (very limited types of services and specific circumstances)

A provider who is asserting lawful notice and consent must notify AZ Blue of the consent, as described below.
Note: Waiving billing restrictions through notice and consent is not permitted for air ambulance services.

For more information about requirements for applicable circumstances, visit the Federal Register “Surprise Billing; Part II” page.

The Department of Health and Human Services (HHS) developed standard notice and consent documents under section 2799B-2(d) of the Public Health Service Act (PHS Act):

CMS Notice and Consent form 10780

Tips on how to submit the form so that AZ Blue can identify the corresponding claim and process it outside of the NSA:

• If you submit an electronic claim, include the consent indicator (PWK with value of CK) and submit the Notice and Consent form as correspondence.
• If you submit a paper claim, submit the Notice and Consent form along with the claim.
• To help us identify the claim, add the patient name and member ID, even though these are not included on the federal form.
• To help us identify the provider, add the provider tax ID number and NPI, even though these are not included on the federal form.