When you see a Non-Direct doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs if you see a provider or visit a healthcare facility that isn’t CLIENT Direct.
“Non-Direct” describes providers and facilities that haven’t signed a contract with the CLIENT (the “Plan”). Non-Direct providers may be permitted to bill you for the difference between what the Plan agreed to pay, and the full amount charged for a service. This is called “balance billing.” This amount is likely more than CLIENT Direct 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, for example, when you have an emergency or when you schedule a visit at a CLIENT Direct facility but are unexpectedly treated by a Non-Direct provider.
If you have an emergency medical condition and get emergency services from a Non-Direct provider or facility, the most the Non-Direct provider or facility may bill you is the Plan’s CLIENT Direct cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
When you get services from a CLIENT Direct hospital or ambulatory surgery center, certain providers there may be Non-Direct. In these cases, the most those Non-Direct providers may bill you is the Plan’s CLIENT Direct cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These Non-Direct providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these CLIENT Direct facilities, Non-Direct providers can’t balance bill you, unless you give written consent and give up your protections.
If you believe you’ve been wrongly billed, you may contact the U.S. Department of Health & Human Services at 1-800-985-3059.
Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.