Zelis helps meet new NSA and TiC regulations


The No Surprises Act (NSA), enacted in December 2020, aims to protect patients from surprise medical bills and prohibits billing of the balance for certain off-grid care.

The Coverage Transparency Rule (TiC), released in October 2020, gives consumers a better insight into the cost of services before seeking care and receiving a bill.

We know what you are thinking. The compliance deadline is fast approaching.

We support you.

We also provide legislative expertise and advice to help regimes manage the complexity introduced by both the NSA and the TiC rule.

And although these new requirements add complexity to the processing and administration of healthcare claims, both before and after service, the decision’s most significant impact lies in two key areas: transparency. and member engagement and processing of off-grid (OON) and Payment requests.

How Zelis helps you

Machine Readable Files (MRF)

Zelis machine readable files will meet the MRF Off-Grid (OON) data requirements for OON claims at Zelis cost. We will also offer Network MRF (INN) data with median INN rates for customers whose main networks are owned or managed by Zelis.

Identity cards

Zelis Member ID will enhance ID card capabilities to print compliant ID cards with additional required information including membership deductible, maximum amount payable and information on where to find suppliers on the network.

Advanced Explanation of Benefits (AEOB)

Zelis Member Communications will publish compliant AEOBs (both print and digital) with the ability to handle increased volume.

Supplier directories

Zelis will offer compliant directories for customers whose main networks are owned or managed by Zelis.

Off-grid claims pricing with mid-grid rates

Zelis market-based pricing offers payers a fully outsourced solution that complies with the No Surprises Act (NSA) from the moment it is implemented. In addition, we provide Qualifying Payment Amount (QPA), Supplier Payment Amount, Supplier Settlement, and Independent Dispute Resolution (IDR) assistance.

Market-based pricing calculates reasonable and acceptable refunds based on procedure, provider, and geography.

Expert prepayment negotiation

Zelis Claims Negotiation succeeds through a combination of expertise, proactive supplier outreach and demonstrable validity of market rates, resulting in a high rate of savings held successfully – before payment.

As vendors can no longer balance the member’s bill for NSA claims, their billing practices on those claims are subject to change. Zelis will offer expert advice to negotiate with vendors and integrate median market data for NSA claims.

Payment after payment

Zelis Claims Settlement manages the settlement process on your behalf to ensure compliance by defending, negotiating, and providing the data necessary for a successful settlement, all within the timeframe required by the NSA.

Support for Independent Dispute Resolution (IDR)

As part of the IDR process, Zelis Claim Resolution will leverage our expertise in claims negotiations and resolution, provide data, analysis and reports to support and defend clients in IDR, all within the time frames specified in the NSA.

Information on supplier behavior

Some providers may use the threat of arbitration to persuade payers to settle for higher refunds. Zelis will help you understand the impact of different pricing strategies and their likelihood of acceptance. Zelis will collect, aggregate and analyze claims settlement and arbitration data to develop a predictive model that illustrates the overall effectiveness of pricing and arbitration outcomes, and how these evolve over time.

The conclusion

The No Surprises Law and the Transparency of Coverage Rule will impact all healthcare organizations, from large healthcare plans and systems to small medical practices and individual providers. As such, healthcare industry leaders must either directly understand the details of the legislation before it is implemented or have a trusted advisor with legislative expertise who can guide them to appropriate solutions.

Zelis can help you.

To learn more about NSA compliance, contact your Zelis representative or contact us here.

For more information, visit the Zelis No Surprises Act information center.

As a leading healthcare payment company, Zelis rates, pays and explains healthcare for healthcare payers, providers and consumers. Zelis was founded on the belief that there is a better way to determine the cost of a healthcare claim, manage payment data, and complete the payment. We partner with over 700 payers including the 5 major national health plans, Blues plans, regional health plans, TPAs ​​and self-insured employers, 1.5 million providers and millions of members , allowing the health sector to pay for care, with care.


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