Arbitrations

The Out-of-network Consumer Protection, Transparency, Cost Containment, and Accountability Act, (P.L.2018, c.32), (“Act”), was signed into law on June 1, 2018, and became effective on August 30, 2018. This Act provides enhanced protections for consumers who receive health care services from out-of-network providers at a participating hospital for urgent, emergent, and inadvertent care.
You may file C.32 OON arbitration application if it meets the eligibility listed below:

  1. On the date of service, the covered person was enrolled in an insured benefits plan issued in New Jersey, a self -funded plan that opts in to C32 OON arbitration, the State Health Benefits Plan, the School Employees Health Benefits Plan, or a Multiple Employer Welfare Arrangement, and
  2. Services were rendered by an out-of-network provider, licensed, or certified in New Jersey, on or after August 30, 2018, on an inadvertent, emergency, or urgent basis.
  3. The carrier has determined the out-of-network provider’s billed charges to be excessive and negotiations between the out-of-network provider and the carrier in the 30-day period following claim finalization have not resulted in a settlement
  4. The difference between the carrier’s final offer and the out-of-network provider is $1000 or more.

While N.J.S.A. 26:2SS-1 to -20 permits out-of-network health care providers to apply for arbitration when they disagree with the carrier’s reimbursement for health care services rendered on an inadvertent, emergency, or urgent basis it presents with an additional hassle for providers. Our company will be happy to alleviate you of this headache. Today we have hundreds of awards of fair reimbursement in favor of our clients thus allowing them to maintain their focus on providing the highest level of patient care.

Capital Medical Billing Solutions has been at the forefront of filing provider arbitrations. To date, our company has filed the most arbitration cases in the state since the implementation of A-2039. Subsequently, we were invited to present evidence, showcasing inconsistencies and flaws in the arbitration process at New Jersey State Senate, thus contributing to a more streamlined arbitration process providers are more content with today.

Federal Legislation Arbitrations

President Biden signed into law The No Surprises Act, which takes effect 01/01/22. The arbitration guidelines previously released have similar guidelines to the A-2039 mandate. This legislation is only subject to federal insurance policies. IDRs will be selected by the carriers and providers choosing and the metrics based on IDRS determinations differ from A-2039 in that the arbitrator should pick the amount closest to the median in-network rate negotiated by insurers for that type of care.