No Surprises Act

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs such as a copayment, coinsurance, and/or a deductible. You also may have other costs or have to pay the entire bill if you receive care from a provider that is “out-of-network” for your health plan’s network.

“Out-of-network” means the provider has not signed a contract with your health plan to provide services.  Out-of-network providers may be allowed to bill you for the difference between what your plan agreed to pay and the full amount charged to the plan for a service. This is called “balance billing.” This amount may be more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider that you do not or cannot choose.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility typically may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get at the facility caring for you after you’re in stable condition.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. 

If you get certain other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

Effect of Specific State Rules

The rules above apply only to the No Surprise Act and do not represent any implications of state law. Some states have their own laws relating to balance or surprise billing for out-of-network laboratory or pathology services that may be different from those described here.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.  

When balance billing isn’t allowed, you also have these protections: 

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles) that you would pay if CDx Diagnostics was in-network. Your health plan will pay CDx Diagnostics directly.
• Your health plan generally must:
  • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

  ---

  If you think you’ve been wrongly billed: you may file a complaint with the federal government at https://www.cms.gov/nosurprises/consumers or by calling 1-800-985-3059; and/or file a complaint with your state balance billing regulator, if any, which is identified in the state-specific tabs. 

  Visit https://www.cms.gov/nosurprises for more information about your rights under federal law or visit your home state regulator’s website (included in state links above) for more information about your state balance billing rights.

   

A claims statement that is sent whenever you use your health plan for services or products from a healthcare provider. It shows which patient benefits cover the cost of service from CDx and what the patient might owe. THE EOB IS NOT A BILL.

 The type of services, products, or CPT codes the patient received from CDx.

The date(s) the sample was collected from the patient.

The full amount billed by CDx to the patient’s insurance.

The maximum amount of the billed charge an insurance company deems is payable by the plan for covered services rendered by providers. The allowed amount permitted by an insurance company can be determined by provider contracts.

The amount patients need to pay each year for covered services before the plan starts paying benefits.

A set amount that patients pay for certain covered services such as office visits or prescriptions.

A percentage of covered expenses that patients pay after they meet their deductible.

The portion of the amount billed that was not covered or eligible for payment under the patient’s plan. Examples include charges for services that are deemed not medically necessary, experimental/investigational, duplicate claims, no prior authorization on file, etc.

The portion of the charges eligible for benefits (allowed) minus copay, deductible, coinsurance, and the amount paid by another source up to the billed amount.

The maximum patient responsibility for self-pay is:

$880.00 per/WATS3D biopsy

$807.35 per/OralCDx Brush Biopsy

This section details the portion of the bill that is the patient’s responsibility to pay. This amount might include copays, deductibles, coinsurance, any amount over the maximum reimbursable charge, or for products/services not covered by the plan. If the patient received a payment intended for a provider, it is their responsibility to pay the provider.

No Surprises Act

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs such as a copayment, coinsurance, and/or a deductible. You also may have other costs or have to pay the entire bill if you receive care from a provider that is “out-of-network” for your health plan’s network.

“Out-of-network” means the provider has not signed a contract with your health plan to provide services.  Out-of-network providers may be allowed to bill you for the difference between what your plan agreed to pay and the full amount charged to the plan for a service. This is called “balance billing.” This amount may be more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider that you do not or cannot choose.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility typically may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get at the facility caring for you after you’re in stable condition.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. 

If you get certain other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

Effect of Specific State Rules

Some states have their own laws relating to balance or surprise billing for out-of-network laboratory or pathology services that may be different from those described here, including the states listed below. The links below contain state specific balance billing information and resources, including contact information for state agencies that may be able to help you further. 

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.  

When balance billing isn’t allowed, you also have these protections: 

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles) that you would pay if Labcorp was in-network. Your health plan will pay Labcorp directly.
• Your health plan generally must:
  • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

  ---

  If you think you’ve been wrongly billed: you may file a complaint with the federal government at https://www.cms.gov/nosurprises/consumers or by calling 1-800-985-3059; and/or file a complaint with your state balance billing regulator, if any, which is identified in the state-specific tabs. 

  Visit https://www.cms.gov/nosurprises for more information about your rights under federal law or visit your home state regulator’s website (included in state links above) for more information about your state balance billing rights.

   

When offered, these notes provide general information about the claim and may also provide a specific explanation of activity that occurred in the Amount Not Covered, Amount Paid by Another Source, and What Your Plan Paid fields. For example, if the claim was denied because your provider submitted the same claim twice, a note would state that the payer denied the claim as a duplicate.