Last Updated: Wednesday, October 01, 2025
The No Surprises Act is intended to provide greater consumer protections to patients by addressing surprise medical bills at the federal level. The Act affects what is required of providers in Highmark’s network, including:
The following applies to members in Highmark’s commercial fully insured, self-funded (ASO) and Affordable Care Act (ACA) plans. It does not apply to the Children’s Health Insurance Plan (CHIP), Medicare Advantage, or Medigap plans.
1 To ensure that Highmark can properly identify claims involving members who receive non-emergency out-of-network services in connection with an in-network facility visit, professional providers must include the facility NPI and Service Facility Name in the Service Facility Loop (Box 32) on all submitted claims. See image below:
2 Highmark will continue to pay members directly for services received from out-of-network ground and water ambulance service providers.
3 Certain narrow exceptions to the prohibition on balance billing have been established, as follows:
4 If the out-of-network provider is not satisfied with the payment Highmark authorizes, they may attempt to negotiate a higher reimbursement with us. If Highmark and the out-of-network provider are not able to negotiate and agree on the final payment, either party may access a new Independent Dispute Resolution (IDR) process created by the No Surprises Act to resolve the dispute.
5 Continuity of care does not include contract terminations based upon failure of the provider to meet applicable quality standards or fraud.