Among other requirements, the No Surprises Act’s Transparency in Coverage Regulations obligates TPA’s, group health plans and insurers to provide advanced EOBs for scheduled services beginning in January 2022. This will allow patients to know what most health care services will cost prior to undergoing treatment. For insurers and health plans, it’s likely to significantly increase administrative costs – not to mention the scramble to put processes and systems in place to meet the requirements by the January 1st deadline.

For providers and health care facilities, the new regulations require inquiring whether a participant has health insurance no later than one business day after a medical appointment is made if the appointment is made at least three business days in advance, or no later than three business days after the medical appointment is made if it’s made at least 10 business days in advance. Plan participants may also request an advanced EOB for services they would like to schedule. 

Under the new regulations, plans may provide advanced EOBs by mail or electronically, as requested by the patient. For the advanced EOBs themselves, there are also requirements on what must be included. Here’s a look at some of the most important aspects:

#1 The network status of each provider and facility, as well as contract rates for services schedule to be received for in-network providers, or a good-faith estimate supplied by the plan provider if the provider is out-of-network.

#2 The expected participant cost-sharing amount as of the date of the notice.

#3 The estimated amount the participant has accrued toward their annual deductible and annual out-of-pocket maximum.

#4 Any medical management requirements for procedures, such as prior authorizations, step-therapy or fail-first protocols. 

#5 A disclaimer that all information is estimated and is subject to change.

If your company is working through the challenges of implementing the new Transparency in Coverage regulations, Integrated Payor Solutions can help. Find out how our secondary claims processing system can efficiently and cost effectively support the new requirements: