External Arbitration Process for Out-of-Network Surprise Bills
Under Missouri law, out-of-network providers have the right to request arbitration proceedings related to disputes between their billed amount and the amount paid by a patient’s health insurance carrier.
What situations qualify?
For a situation to qualify under Missouri’s arbitration law, Section 376.690 RSMo the patient must seek treatment for an emergency medical condition at an in-network facility. During their stay, any charges for unanticipated out-of-network services by an out-of-network provider could qualify for arbitration.
How Does it work?
Within 45 processing days of receiving the out-of-network provider’s professional claim, the health insurance carrier shall offer to pay the provider a reasonable reimbursement. If the out-of-network provider declines the health carrier’s initial offer of reimbursement, the health carrier and the provider have 60 days from the date of the initial offer of reimbursement to negotiate in good faith to determine a mutually agreed upon reimbursement amount. If they do not agree to a reimbursement amount by the end of the 60 day negotiation period, the dispute may be resolved through the arbitration process. To initiate the arbitration proceedings, either the health carrier or the out-of-network provider must provide written notification to the director of the Missouri Department of Commerce & Insurance, and to the other party within 120 days of the end of the negotiation period.
The patient may not be balance billed by out-of-network providers for the unanticipated out-of-network services beyond in-network cost-sharing.
How to Notify the Director
Notice of an intent to arbitrate should be sent to the director via email at firstname.lastname@example.org. Requests may also be submitted in writing and mailed to the department at:
Missouri Department of Commerce & Insurance
Attn: Division of Consumer Affairs
P.O. Box 690
Jefferson City, MO 65102
The notice should indicate the provider or health carrier’s intent to arbitrate and include the original billed amount and the date and amount of the final offer by each party.
Upon receipt of an arbitration notice, the department will review the request to determine if it qualifies for arbitration pursuant to Section 376.690 RSMo. If approved, the party requesting the arbitration will receive written notice from the department advising which arbitration entity was chosen and how to file a request for arbitration with that entity. Per the aforementioned statute, our department does not facilitate the filing of an arbitration request. Once it is determined the situation qualifies for arbitration under the law, it is incumbent upon the petitioner to file the actual request. The cost of arbitration shall be shared equally amongst the petitioner and respondent. Claims may be combined into one arbitration request, but only to the extent the claims represent similar circumstances and services provided by the same health care professional.
20 CSR 400-14.100 requires the department to publish on its website the list of arbitration entities it utilizes for arbitration services. Currently, the department utilizes the American Health Law Association for arbitration requests.
For questions regarding arbitration or out-of-network surprise balance bills, please contact the department at:
Consumer Hotline: 800-726-7390