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Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations payment amount for an item or service billed under the related service code.
ii For an item or service furnished in a subsequent year before the first sufficient information year for such item or service with respect to such plan or coverage or before the first year for which an eligible database has sufficient information to a calculate a rate under paragraph c3i of this section in the immediately preceding year, the plan must calculate the qualifying payment amount by increasing the qualifying payment amount determined under paragraph c4i of this section or this paragraph c4ii, as applicable, for such item or service for the year immediately preceding such subsequent year, by the percentage increase in CPIU over such preceding year;
iii For an item or service furnished in the first sufficient information year for such item or service with respect to such plan or the first year for which an eligible database has sufficient information to calculate a rate under paragraph c3i of this section in the immediately preceding year, the plan or issuer must calculate the qualifying payment amount in accordance with paragraph c3 of this section.
d Information to be shared about qualifying payment amount. In cases in which the recognized amount with respect to an item or service furnished by a nonparticipating provider, nonparticipating emergency facility, or nonparticipating provider of air ambulance services is the qualifying payment amount, the plan must provide in writing, in paper or electronic form, to the provider or facility, as applicable 1 With an initial payment or notice of denial of payment under 54.9816
4T, 54.98165T, or 54.98171T:
i The qualifying payment amount for each item or service involved;
ii A statement to certify that, based on the determination of the plan A The qualifying payment amount applies for purposes of the recognized amount or, in the case of air ambulance services, for calculating the participants, beneficiarys, or enrollees cost sharing; and B Each qualifying payment amount shared with the provider or facility was determined in compliance with this section;
iii A statement that if the provider or facility, as applicable, wishes to initiate a 30-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-day negotiation period does not result in a
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determination, generally, the provider or facility may initiate the independent dispute resolution process within 4 days after the end of the open negotiation period; and iv 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.
2 In a timely manner upon request of the provider or facility:
i Information about whether the qualifying payment amount for items and services involved included contracted rates that were not on a feefor-service basis for those specific items and services and whether the qualifying payment amount for those items and services was determined using underlying fee schedule rates or a derived amount;
ii If a plan uses an eligible database under paragraph c3 of this section to determine the qualifying payment amount, information to identify which database was used; and iii If a related service code was used to determine the qualifying payment amount for an item or service billed under a new service code under paragraph c4i or ii of this section, information to identify the related service code; and iv If applicable, a statement that the plans contracted rates include risksharing, bonus, penalty, or other incentive-based or retrospective payments or payment adjustments for the items and services involved as applicable that were excluded for purposes of calculating the qualifying payment amount.
e Certain access fees to databases. In the case of a plan that, pursuant to this section, uses an eligible database to determine the qualifying payment amount for an item or service, the plan is responsible for any costs associated with accessing such database.
f Audits. See 45 CFR 149.140f for audit procedures that apply with respect to ensuring that a plan is in compliance with the requirement of applying a qualifying payment amount under 54.98164T, 54.98165T, 54.9817
1T, and this section, and ensuring that such amount so applied satisfies the requirements under this section, as applicable.
g Applicability date. The provisions of this section are applicable with respect to plan years beginning on or after January 1, 2022.

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54.98167T Complaints process for surprise medical bills regarding group health plans temporary.

See 45 CFR 149.150 for the process to receive and resolve complaints that a specific group health plan may be failing to meet the requirement of applying a qualifying payment amount under 54.98164T, 54.98165T, 54.98166T, and 54.98171T, which may warrant an investigation.
54.98171T Preventing surprise medical bills for air ambulance services temporary.

a In general. If a group health plan provides or covers any benefits for air ambulance services, the plan must cover such services from a nonparticipating provider of air ambulance services in accordance with paragraph b of this section.
b Coverage requirements. A plan described in paragraph a of this section must provide coverage of air ambulance services in the following manner 1 The cost-sharing requirements with respect to the services must be the same requirements that would apply if the services were provided by a participating provider of air ambulance services.
2 The cost-sharing requirement must be calculated as if the total amount that would have been charged for the services by a participating provider of air ambulance services were equal to the lesser of the qualifying payment amount as determined in accordance with 54.98166T or the billed amount for the services.
3 The cost-sharing amounts must be counted towards any in-network deductible and in-network out-of-pocket maximums including the annual limitation on cost sharing under section 2707b of the Public Health Service Act as applicable applied under the plan and the in-network deductible and out-of-pocket maximums must be applied in the same manner as if the cost-sharing payments were made with respect to services furnished by a participating provider of air ambulance services.
4 The plan must i Not later than 30 calendar days after the bill for the services is transmitted by the provider of air ambulance services, determine whether the services are covered under the plan and, if the services are covered, send to the provider an initial payment or a notice of denial of payment. For purposes of this paragraph b4i, the 30-calendar-day period begins on the date the plan receives the information necessary to decide a claim for payment for the services.

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