What is QPA?
The Qualified Payment Amount (QPA) was established by the Consolidated Appropriations Act – No Surprises Act. The QPA is the derived from the plan’s median contracted rate for a particular service, accounting for multiple factors and adjusted for market consumer price index in urban areas (CPI-U).
The lessor of the QPA or billed charges must be used to calculate the member’s cost-sharing on a “surprise billing” claim and this rate is also the amount Blue KC has made the allowable for the non-participating provider’s payment on the claim.
The QPA is a primary factor that will be considered during the arbitration process if a provider does not agree with a payor’s initial payment and invokes the Independent Dispute Resolution (IDR) process.
This notice certifies the Qualified Payment Amount (QPA) applies for purposes of the recognized amount pursuant to 45 CFR §149.140. This QPA was determined in accordance with the methodology outlined by CMS.
Per the requirements of the No Surprises Act, balance billing the member for the difference between the allowable (QPA) and billed charges may be prohibited. If you wish to initiate a 30-day open negotiation period for purposes of determining the amount of total payment, please complete the required Open Negotiation Notice (dol.gov). The initiating party must provide this notice within 30 business days of the receipt of initial payment or notice of denial of payment for the item or service. The open negotiation period begins on the day that the initiating party sends the open negotiation notice. Please email the Open Negotiation Notice or any questions to SurpriseBilling@bluekc.com. Blue KC may be reached at 816-395-3929.
If the negotiation does not result in a determination, you may initiate the Independent Dispute Resolution process within four days after the 30-day negotiation period. More information can be found at: No Surprises Act | U.S. Department of Labor (dol.gov)