Downcoding Explanations for NSA Claims by Nonparticipating Providers

As part of ensuring we’re appropriately reimbursing for our members’ care, there are some situations in which we may recode a claim. We notify you when we do this on your provider claim summary. Under the U.S. Departments of Health and Human Services, Labor and the Treasury Requirements Related to Surprise Billing: Final Rules, we are in the process of updating that notice for items and services subject to the No Surprises Act (NSA) requirements.

On NSA-eligible claims, we will provide:

  • Information when we change a code you submitted to a code associated with a lower Qualifying Payment Amount (QPA). The Final Rules refers to this as “downcoding.”
  • An explanation of why we recoded and applied a different QPA. 
  • The QPA of the code you submitted and the one we paid. The NSA and related rules provide how the QPA is calculated, generally reflecting our median contracted rate for an item or service in the geographic area.

While we work on the updates, we want you to know about common situations in which we may change a code. Sample situations where downcoding may apply include when a provider submits:

  • New-patient procedure codes for an established patient
  • Two or more procedure codes when a single, comprehensive procedure code more accurately captures the service
  • Procedure codes inconsistent with a member’s age, based on dates of birth and service

Learn more: The NSA is part of the Consolidated Appropriations Act (CAA) of 2021 and the Transparency in Coverage Final Rule.