No Surprise Billing Act
You have reached this page as a result of your claim being priced using the No Surprises Act, below are the instructions to contact the pricing vendor if you wish to dispute the payment amount.
Federal
The Federal No Surprise Billing Act was applied to the processing of this claim. The patient is not responsible for the difference between the amounts reflected in the covered charge and benefits allowed columns. Payment amounts are eligible for dispute by contacting Zelis at NSA@Zelis.com or calling 1-888-266-3053. within 30 days. You have 4 business days following the conclusion on the Open Negotiation period to initiate the Independent Dispute Resolution process.
The Allowed Charges is equal to the Qualifying Payment Amount (QPA). The QPA applies for purposes of the recognized amount for calculating the patient's cost sharing. The QPA was determined in compliance with the methodology for calculating the QPA under federal law.
Ohio
State regulations relating to an out-of-network care were applied to the processing of this claim. The patient is not responsible for the difference between the amounts reflected in the covered charge and benefits allowed columns. Payment amounts are eligible for dispute by contacting Zelis at NSA@Zelis.com within 30 business days. If Open Negotiation has not successfully concluded within 30 days, you may initiate Independent Dispute Resolution if (a) the service in question was not provided more than one year prior to the request and (b) the billed amount exceeds $750. You may bundle up to 15 claims as long as the sum is greater than $750.