Transparency in Coverage Regulation and Consolidated Appropriations Act
External FAQs for JAA and MCS1

For purposes of this document, TPA refers to both a third-party administrator and aself-administered plan.

Note: For ASO/FI clients, please see the ASO/FI FAQ document.
Last Update: July 2024 (gray highlight indicates updates)**The information in this document does not constitute legal advice.
Customers should consult their legal team for further questions or advice.**
Transparency in Coverage – Final Regulation
GeneralAnthem supports meaningful transparency efforts that help consumers make informed health caredecisions. In August 2021, the Department of Labor, in conjunction with the Departments of Health andHuman Services (HHS) and the Treasury, (known collectively as the Tri-Agencies) issued updated guidance
related to implementation of the Consolidated Appropriations Act (CAA) and Transparency in Coverage(TIC) final rule. The guidance delayed enforcement and provided good faith compliance safe harbors
related to the implementation of a number of provisions of the CAA and TIC.
Due to the operational complexities and timeline challenges, the enforcement of key provisions including
the prescription drug machine-readable file and advance explanation of benefits – has been deferredpending further guidance. This delayed enforcement provides much needed additional time to
implement the requirements, while giving the Tri-Agencies time to align overlapping requirements andprovide technical guidance for public comment and rulemaking.
The TIC regulation (Regulation) requires health insurers and group health plans (Health Plans) to make aninternet-based self-service tool available to enrollees beginning on January 1, 2023, that contains
personalized out-of-pocket cost information and the underlying negotiated rates for 500 covered
healthcare items and services, Health Plans expanded those tools to cover all items and services effective
January 1, 2024. CMS has indicated it will issue additional guidance on this provision and how it relates
to the CAA price comparison requirements. The rule also required Health Plans to make public machinereadable files (MRF) beginning on July 1, 2022 (delayed from January 1, 2022) that contain thenegotiated rates with in-network providers for all covered items and services as well as historical1

MCS product is only sold in California.

1payments to and billed charges from out-of-network providers. The requirement to post an MRF
containing the in-network negotiated rates and historical net prices for all covered prescription drugs byplan or issuer at the pharmacy location level is pending technical requirements and an implementation
timeline, which the Tri-Agencies will provide in future guidance. The purpose of the rule is to provide
transparency that federal regulators believe will promote consumer choice and competition amongproviders. In instances where rates cannot be disclosed in specified amounts (e.g., dollar), the TriAgencies will use a case-by-case approach to determine whether enforcement is appropriate.
Anthem will be issuing amendments to its JAA and MCS agreements on renewal to reflect the services
Anthem will be providing under both the Transparency in Coverage regulation and the CAA as described at
the end of this FAQ.
What areas will Anthem take responsibility for and make updates to be in compliance?
Anthem developed an implementation strategy for achieving the Transparency requirements, which isto provide a compliant solution which applies equally to its fully insured and self-funded clients for thedata we administer and maintain.
How will carve-out situations be handled?
In situations where a group has a vendor other than Anthem for certain services (e.g. Pharmacy),
Anthem’s pricing and rate information will not apply. Therefore, the group may need to make additionalarrangements.
What areas does Anthem feel are already in compliance with no change needed? Where are thecurrent tools relative to the requirements as they are outlined by effective dates?
While Anthem does have member transparency tools in place and available currently for much of ourbusiness, changes have been implemented based on the current language in the Transparency in
Coverage regulation. Additional rulemaking is anticipated.
Will you support the client’s communication to their members on these changes and new
resources?
We do anticipate communicating with clients as to our implementation activities for these laws.
Clients may use these communications to develop communications for their members.
List any subcontractors or third parties who are providing assistance to you in complying with the law
and regulations, or who will be involved in work you may perform on behalf of the Plan.
Anthem does not plan to use subcontractors for the machine-readable file. Use of subcontractors forother services will be determined once regulations are issued.
What plans are subject to the Transparency Rule?
According to the Regulation, the Transparency Rule applies to health insurance issuers in the groupand individual markets. It also applies to group health plans, including group health plans that are
fully insured, as well as those that are self-funded. It also applies to Qualified Health Plan issuers andthe Federal Employees Health Benefits Program. The Rule does not, however, apply to Medicare
Advantage, Medicare Supplement, Medicaid MCO coverage, or vision or dental only plans. Nor does
the Transparency Rule apply to grandfathered health plans or to short term, limited duration
insurance.

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Machine Readable Files
What is a machine-readable file?
A machine-readable file is defined as a digital representation of data or information in a file that can beimported or read by a computer system for further processing without human intervention, while
ensuring no semantic meaning is lost. The final rules require each machine-readable file to use a nonproprietary, open format. The machine-readable files for the data we administer and maintain will bemade accessible through anthem.com. Clients can link to those files; but due to the size of the files, wewill not be providing the data directly to our clients for them to put on their websites. Anthem will only
be publishing the data it maintains, so if a plan uses a third-party vendor, such as a PBM, then thegroup should work with that vendor to determine whether it is providing a similar solution.
For JAA, we post the data attributable to network and non-network claims. Once additional regulatory
guidance is issued, we will also provide the pharmacy information if pharmacy is purchased from
Anthem.
For MCS, we post the data attributable to network claims only, since that is based on our contracted feeschedules.
Will you build and manage the publicly accessible website with all required machine-readable files onbehalf of your clients?
The machine-readable files for the data we administer and maintain are made accessible throughanthem.com. The data are posted in compliance with the requirements. Clients can link to those files;
but due to the size of the files, we will not be providing the data directly to our clients for them to put
on their websites. Anthem will only be publishing the data it maintains, so if a plan uses another vendor,
such as a PBM, then the group should work with that vendor to determine whether it is providing asimilar solution.
What are machine-readable files intended to be used for?
According to the preamble to the Transparency in Coverage rule, the purpose of the files is to allow “thepublic to have access to health coverage information that can be used to understand health care pricing andpotentially dampen the rise in health care spending.” The government expects private entities to createapps or websites to enable consumers to view and compare this rate information. Once again, the files are“machine readable,” so consumers must rely on someone with a computer program and system capability
to digest the files and render them viewable.
Members can log in to anthem.com and use our cost transparency tools such as Find Care and Virtual Careto shop for health services and understand how costs differ from provider to provider.
How often will the machine-readable files be updated?
The regulation outlines that the files are required to be updated monthly on the first of each month.
Will there be a cost for compliance with the machine-readable file requirement?
There will be no additional charge for this specifically. However, the new regulations will be taken into
consideration when determining our administrative fees.

3Will you create these files and/or the website internally or utilize a subcontractor? If you are using a
subcontractor, will you offshore?
We create these files internally.
Will the publicly available files be accessed through the current participant portal or be located in a
new portal? Can plan sponsors link to the files?
These files are accessible through anthem.com on a publicly available website. Plan sponsors may link tothose files as desired.
How will client-specific machine-readable files be accessed on anthem.com?
Beginning July 1, 2022, Anthem has been publishing the machine-readable files for the plans weadminister and maintain. These files are published on anthem.com and can be accessed using this link:
https://www.anthem.com/machine-readable-file/search. This link can be added to the group healthplan’s public website to fulfill the group health plan posting requirement. This link will allow you tosearch for your files using your Employer Identification Number (EIN).
What is an EIN?
An Employer Identification Number (EIN) is a unique nine-digit identification code issued by theInternal Revenue Service (IRS) to a business. The CMS file layout requires group rate information to beloaded using the group EIN.
How will you monitor and validate your processes to ensure the ongoing accuracy of the data in thefiles?
Quality Audit (QA) processes are an integral part of our monthly file postings. Validation occurs at all points
in the process including ensuring the source data from the multiple systems is being pulled in correctly,
validating results of the data from the source system pull, and validation of data as it appears in production.
May a group health plan that does not have its own website satisfy the requirements of the TIC Final
Rules with respect to posting the Allowed Amount file and the In-network Rate file on a public
website of the plan, if the plan’s service provider posts the Allowed Amount file and the In-network
rate file on its public website on behalf of the group health plan?
Per CMS FAQ #37 published on June 17, 2022, (https://www.cms.gov/healthplan-pricetransparency/resources/technical-clarification), if a group health plan does not have a public website, theplan may satisfy the requirements for posting the Allowed Amount file and the In-Network file by entering
into a written agreement under which a service provider (such as a TPA) posts the Allowed Amount file andthe In-network Rate file on its public website on behalf of the plan. However, if a plan enters into anagreement under which a service provider agrees to post the Allowed Amount file and the In-network Rate
file on its public website on behalf of the plan, and the service provider fails to do so, the plan violates these
disclosure requirements. The Departments intend to follow up with the issuance of formal guidance soon.
How do I know which file to pick for my product?
For the files posted by Anthem, the JSON File naming convention reflects the product name (e.g., PPO,
HMO).
Please describe how Anthem will respond to questions regarding the files.
Please contact your TPA for any specific questions regarding the files. Your TPA will ensure that the questionis routed to the appropriate team for response.

4Will you provide the plan with any of the three machine readable files on a monthly basis including innetwork rates, out-of-network allowed amounts, and prescription drug negotiated rates (for drugs
dispensed under the medical plan)?
No, the machine-readable files will only be made available on anthem.com.
How do you handle rates for providers that have been terminated?
Terminated providers will be dropped each month and new provider records will be added. Changes will bereflected in the files the month after the termination.
Will the machine-readable files be archived and how will the archived files be accessed?
The files will be archived according to the legal retention period of 10 years. If a regulator requests
information associated with a file, please reach out to us and we will work with the regulator to get the
information they need. The client also has the ability to download and archive.

Cost Transparency Tool
The Transparency in Coverage regulation requires health insurers and group health plans to make aninternet-based self-service tool available to enrollees beginning on January 1, 2023, that contains
personalized out-of-pocket cost information and the underlying negotiated rates for 500 covered healthcare items and services; health plans expanded those tools to cover all items and services effective
January 1, 2024.
The CAA also requires plans to make available to members a price comparison tool to enable a member
to compare the amount of cost-sharing the individual would be responsible for paying under the planwith respect to a specific item or service by a participating provider.

The answers in this section pertain to JAA plans only. For MCS, we expect that TPAs2 canaccess the machine-readable files in order to get pricing to produce their own costtransparency tool.
Will Anthem make the tool available to plan participants?
Anthem has updated its “Find Care” tool based on the mandates. The tool is based on data that Anthem has
for Client and is based on Anthem’s standard administration, such as processing of preventive care claims,
and estimated out-of-network rate information. The estimated out-of-network rate information provided
through the tool is not Provider-specific and, if Anthem does not provide utilization management services
for Client, the tool will not provide detail as to whether prior authorization is required.
2

TPA refers to both self-administered plans and third-party administrators.

5Consolidated Appropriations Act (CAA) - Law pending final regulations
GeneralThe CAA represents the most significant changes to the private insurance market since the Affordable
Care Act. The law:••••

Requires plans to develop and make available price transparency tools, good faith estimates andan advanced explanation of benefits
Restricts “surprise billing”
Prohibits “gag clauses” in healthcare contracts
Adds new mandates for ID cards, provider directories and continuity of care.

These provisions are described in more detail below but note that much of the important detail of thislaw will be determined by regulations that will be released in future rulemaking.
Anthem is working alongside other stakeholders to assess the operational complexities and timelines
for implementation and continues to make recommendations to the Tri-Agencies who must developthese regulations.
Who does this law apply to?
All types of client plans, including self-funded clients as well as health insurance issuers in theindividual and group markets.
What types of plans are excluded from the scope of the CAA?
• Short-Term Limited Duration plans• Government Plans (e.g. Medicare, Medicaid)• Retiree Only Plans• Account Based Plans (e.g. HRA, HSA) Note: The underlying health plan (e.g. High Deductible HealthPlan (HDHP) is in the scope of the CAA.
• Excepted Benefits (e.g. Standalone Dental or Vision)
What is the effective date of the Law?
The CAA included numerous provisions, the majority of which become effective January 1, 2022.
The requirement for plans to provide a good faith estimate of charges and an Advance Explanation ofBenefits (AEOB) when notified of a scheduled service by a provider are delayed, pending future
regulatory guidance, with no final date set.
The Tri-Agencies also announced they would issue regulations to implement the ID card, provider
directory, gag clauses on price and quality data, and continuity of care requirements, but would not doso prior to January 1, 2022. Plans are expected to implement based on a good faith, reasonableinterpretation of the requirements by the January 1, 2022, compliance date.
Will there be a cost for compliance with the CAA?
Except for the Independent Dispute Resolution process, for plan years commencing 2023, there
will be no additional charge for compliance changes, however, the new regulations will be taken
into consideration when determining our administrative fees.
6How does the Transparency in Coverage regulation relate to the transparency requirements includedin the “No Surprises Act” aka the Consolidated Appropriations Act (CAA) published at the end of 2020?
These two separate laws make sweeping changes to the health care industry in an effort to further
promote transparency. Although separate, they include overlapping provisions, notably the pricecomparison tool requirements.
The Regulation requires health insurers and group health plans to make an internet-based self-service
tool available to enrollees beginning on January 1, 2023, that contains personalized out-of-pocket cost
information and the underlying negotiated rates for 500 covered health care items and services; HealthPlans expanded those tools to cover all items and services effective January 1, 2024.
The CAA also requires a price comparison tool; however, the requirements are not nearly as detailed asthen tool considered under the Transparency in Coverage regulation. It still requires insurers to publish
a tool for members allowing comparison of cost sharing amount for covered items and services.
The CAA also includes other transparency initiatives beyond the separate Transparency in Coverage
requirements including:
1. Out-of-network providers to deliver to the patient’s health plan a “good faith effort of an
estimated amount” of all billing and services;
2. Providers to make available on their publicly available website information on their pricing forservices;
3. Health Plans to provide members with an Advanced Explanation of Benefits (AEOB) prior toscheduled care or upon patient request;
4. Health Plans to maintain up to date provider directories; and,5. Health Plans to remove gag clauses in their par-provider contracts.
On August 20, 2021, the Tri-Agencies announced a delay in enforcement of certain provisions of the
CAA. Specifically, enforcement of the price comparison tool requirements in the CAA were delayed
until January 1, 2023, to align with the Transparency in Coverage regulation effective dates. The TriAgencies said they would use the delay to propose rules and seek public comment regarding whether
compliance with the Transparency in Coverage regulation would satisfy the requirements to create aprice comparison tool under the CAA.
Will you support the plan’s communication to members on these changes and new resources?
We do anticipate communicating with groups as to our implementation activities for these laws. Groups
may use these communications to develop communications for their member.
Are any subcontractors or third parties providing assistance to you in complying with the law andregulations, or who will be involved in work you may perform on behalf of the Plan?
Anthem does not plan to use subcontractors for the machine-readable file. Use of subcontractors forother services will be determined once regulations are finalized.

Price Comparison Tool
The CAA requires plans to make available to members a price comparison tool to enable a member tocompare the amount of cost-sharing the individual would be responsible for paying under the plan withrespect to a specific item or service by a participating provider.
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On August 20, 2021, the Tri-Agencies announced delays in enforcement of key provisions of the CAA.
Specifically, enforcement of the price comparison tool mandate was delayed until January 1, 2023.
The intent is to align the requirements of the Transparency in Pricing regulation with the Price
Comparison tool requirements of the CAA. Additional rulemaking guidance is anticipated.
For more information, please see the Cost Transparency Tool section above.

Provider Directory
The CAA requires plans to establish a verification process to confirm provider directory information atleast every 90 days, including removing providers or facilities who are non-responsive. Plans must also
develop a response protocol to respond to member network questions. Members who receive
inaccurate information that a provider is in-network can only be liable for in-network cost-sharing.,
On August 20, 2021, the Tri-Agencies announced they will issue regulations to implement the provider
directory requirements but would not do so prior to January 1, 2022. These regulations or otherregulatory guidance has not yet been issued. However, Health Plans are expected to implement basedon a good faith, reasonable interpretation of the requirements by the January 1, 2022, compliance datewith a primary focus on ensuring members who rely on provider directory information that inaccurately
depicts a provider’s network status are only liable for in-network cost sharing amounts.
Will a provider directory be available and kept up-to-date?
Yes.
Will directory be available electronically and/or printed?
Yes, this is current state.
Will you accept responsibility for directory inaccuracies resulting in added plan cost?
The indemnification provision in the JAA or MCS agreement with Anthem will apply.
Will you comply with the provider directory requirements on behalf of your groups?
Yes, however, much of the important detail of CAA provisions will be determined by future regulatory
guidance.
How often will you update the directory?
Those processes will be determined as a part of our design based on implementation guidance from thefinal regulations.
Will you notify TPAs of the update?
No.
Will the versions be dated, so TPAs will know the updates are current?
Those processes will be determined as a part of our design based on implementation guidance from thefinal regulations.
How will access to the directory be provided (i.e., directly or via a plan sponsor website)?
The provider directory is/will be available through our website.

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Mental Health Parity
What do the Strengthening Parity in Mental Health (MH) and Substance Use Disorders (SUD)
provisions do?
Included as part of the Consolidated Appropriations Act of 2021 (commonly referred to as theConsolidated Appropriations Act (CAA)) were several measures intended to strengthen parity in MH/SUD
benefits, specifically with Non-Quantitative Treatment Limitations (NQTLs). Importantly, if a group healthplan that provides both Medical/Surgical (MS) benefits and Mental Health/Substance Use Disorder(MH/SUD) benefits and imposes NQTLs on MH/SUD benefits, the plan has to perform testing and maketesting results available to the Tri-Agencies, or any state authority, upon request within 45 days ofenactment of the Act (generally, no later than February 10, 2021). Plans must also document and makeavailable the following information:
1. The specific plan or coverage terms or other relevant terms regarding the NQTLs and a
description of all MH/SUD and MS benefits to which each such term applies in each respective
benefits classification.
2. The factors used to determine that the NQTLs will apply to MH/SUD benefits and MS benefits.
3. The evidentiary standards used for the factors identified in 2 above when applicable, provided
that every factor shall be defined, and any other source or evidence relied upon to design andapply the NQTLs to MH/SUD benefits and MS benefits.
4. The comparative analyses demonstrating that the processes, strategies, evidentiary standards,
and other factors used to apply the NQTLs to MH/SUD benefits, as written and in operation, arecomparable to, and are applied no more stringently than, the processes, strategies, evidentiarystandards, and other factors used to apply the NQTLs to MS benefits in the benefits
classification.
5. The specific findings and conclusions reached by the group health plan or health insurance
issuer with respect to the health insurance coverage, including any results of the analyses
described above that indicate that the plan or coverage is or is not in compliance.
The Mental Health Parity and Addiction Equity Act (MHPAEA) currently requires NQTL testing, but the
CAA creates more formal analyses and reporting. The DOL can begin requesting a comparative analysis
report from group health plans beginning on February 10, 2021. The DOL will be issuing regulations onthese new requirements.
What is a Non-Quantitative Treatment Limitation (NQTL)?
Mental Health Parity looks at two types of treatment limitations – quantitative and non-quantitative.
Quantitative treatment limitations are the limits that apply to the coverage in the benefit booklets, suchas cost-sharing and visit limits. Non-quantitative treatment limitations are behind-the-scenes
administrative activities that take place but may impact coverage. Examples include credentialing, how
we determine the amounts to pay providers, utilization management, creation of medical policies andcase management. The law requires that we treat behavioral health conditions no less favorably than we
do medical conditions.
Who does this law apply to?
The law applies to all types of group plans, including self-funded clients.
How will Anthem comply with this law?
Anthem has created NQTL analysis for its standard processes and procedures (e.g., Credentialing, CaseManagement, Utilization Review, etc.), which are available free of charge upon request.
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Are you able to conduct and provide a detailed written comparative analysis of the design andapplication of the Non-Quantitative Treatment Limitations (NQTLs) as contemplated by theConsolidated Appropriations Act?
Yes, for the services for which the plan utilizes Anthem’s standard policies and procedures. Anthem has
used the U.S. Department of Labor (DOL) self-compliance tool to analyze its compliance with the NQTL
requirements.
Does the Anthem NQTL analysis apply to all plans subject to the law, whether fully insured or selfgrouped?
The NQTL analysis applies to all fully insured business. To the extent a self-funded group utilizes
Anthem’s standard processes and procedures for the administration of the Plan (e.g., credentialing),
Anthem’s NQTL summaries will be applicable to any inquiries. However, if a group deviates from
Anthem’s standard procedures (e.g., modifies the prior authorization list) or doesn’t use Anthem as avendor for all of its plan administration (e.g., Rx, utilization management), then NQTL analysis would be
the responsibility of the group or its other vendor(s).
Will Anthem provide required NQTL documentation?
Anthem will provide our NQTL analysis upon request, which reflects our standard processes andprocedures. This NQTL analysis can be provided to groups, members, regulators or providers. It will be
updated periodically. However, Anthem will not provide any analysis for NQTLs that are within thegroup’s responsibility (e.g., benefit exclusions, Rx with a non-Anthem vendor, etc.).
Will Anthem perform the NQTL test for JAA/MCS Groups?
If a group uses our standard policies and procedures, our existing NQTL analysis will apply to them. For
other NQTLs that are solely within the group’s control (e.g., benefit design) or a requested deviationfrom our standard process (e.g., change to preauthorization listing), the group would be responsible for
the NQTL analysis because they know why they made that determination. Also, if a group uses a vendor
other than Anthem for an applicable NQTL, such as utilization management or pharmacy services, thenthe group will need to work with that vendor for any NQTL analysis.
What action is Anthem taking from the recent proposed rule on Mental Health Parity?
On July 25, 2023, the U.S. Departments of Health and Human Services (HHS), Labor (DOL), and Treasury(together, the Tri-Agencies) released new proposed rules that if adopted would alter the standards
plans and issuers must meet to comply with the Mental Health Parity and Addiction Equity Act of 2008
(MHPAEA).
Anthem will be meeting with internal subject matter experts to assess the proposed changes andconsider perspectives from trade associations and employer clients as we prepare to develop feedback.
Please keep in mind the guidance is a proposal, and the proposed effective date of January 2025 is subject
to change. Current regulations remain in place, and Anthem continues to operate to demonstratecompliance in accordance with these requirements.
Regardless of the proposal and its impact, Anthem recognizes the importance of mental health services andsubstance abuse services and remain committed to ensuring our clients and members have access to suchservices and care.
10Advance Explanation of Benefits (AEOB)The CAA requires health plans to provide an advance explanation of benefits (AEOB) for scheduled
services at least three days in advance to give patients transparency into which providers are expected toprovide treatment, the network status of those providers, good faith estimates of cost, cost-sharing andprogress towards meeting deductibles and out-of-pocket maximums, as well as whether a service issubject to medical management and relevant disclaimers of estimates.
On August 20, 2021, the Tri-Agencies announced an indefinite delay in enforcement of the AEOB
requirements. No new enforcement date was set.
Although we are awaiting regulatory guidance to confirm and begin implementation of the full solution,
Anthem anticipates that the process that will be used will result in Anthem receiving the AEOB requestfrom providers. We will price the request and send it to the TPA using a separate 837+ file from thecurrent 837 claims file. The TPA will be responsible for generating and sending the AEOB to the member.
The TPA will need to send a response file back to Anthem to close out the open request and a copy of the
AEOB so that Anthem can respond to provider inquiries.
Note: The requirement to send the response back to Anthem is not applicable to MCS business.

Surprise Medical Billing
The CAA includes the “No Surprises Act” which mandates that patients are only responsible for innetwork cost-sharing amounts, including deductibles, in emergency situations and certain nonemergency situations where patients do not have the ability to choose an in-network provider (including
air ambulance providers). The law also prohibits providers from balance billing except in limited
circumstances with patient notice and consent. The act also requires an independent dispute resolution
process for providers and plans who cannot reach an agreement on payment.
Much of the important detail of these provisions will be determined by regulations that will be released
and may be impacted by various court cases. The information provided below incorporates theregulations that were issued on July 1, 2021, and September 30, 2021. On August 19, 2022, the TriAgencies issued “Requirements for Surprise Billing: Final Rules.” We are expecting another final rule on
this provision. The Tri-Agencies have also indicated enforcement discretion until November 1, 2024, forgood faith, reasonable interpretation recalculations of the Qualifying Payment Amount (“QPA”) to occur.
Anthem continues to monitor additional developments on this topic.
What is the Qualifying Payment Amount (QPA)?
The QPA is the lesser of the median contracted rate in the metropolitan service area (MSA) for same orsimilar services and a same or similar provider or billed charge.
Will Anthem determine the Qualifying Payment Amount?
Yes, Anthem will determine the QPA so that the TPA can determine member cost-sharing.
How will Anthem define and evaluate service codes for purposes of determining the QPA?
Anthem will use the definitions outlined in the IFR. Service code means the code that describes an item orservice, including a Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System
11

(HCPCS), or Diagnosis-Related Group (DRG) Code. Given the requirement that a separate QPA be establishedfor each Service Code, Revenue Codes may also be considered Service Codes under the outpatient
methodology. Based on a Final Rule published in August 2022, Anthem is aligning with the calculation of
separate median contracted rates by provider specialty both in instances where its contracting process setsdifferent rates for specialties and where the contracting process results in different rates for different
specialties.
Does the No Surprises Act apply to ground ambulance as well as air ambulance?
No, the law applies only to air ambulance.
Can a JAA Payor utilize the QPA that Anthem supplies as the allowance for provider payment instead of thestandard non-participating provider pricing and if so, will Anthem handle the IDR process?
Yes, the TPA can select the QPA as the payment amount instead of the standard non-participating provider
pricing.
The CAA will require health plans to reimburse out-of-network (OON) providers and facilities in thesituations where balance billing is prohibited. Will Anthem offer services to support this?
Yes, for our JAA plans Anthem is prepared to pay the provider directly where applicable. For MCS, the
TPA is responsible for paying the provider directly.
Will Anthem handle the IDR process for the group?
Anthem will not handle the IDR process for our MCS groups. For our JAA business, it depends If Anthem
pricing is used, Anthem will perform the IDR process. If Anthem pricing is not used, Anthem will only
perform IDR for states in which a Host Blue, as defined in the JAA agreement, processed the claim. The
plan sponsor will be responsible for the IDR process for Anthem’s 14 states.
Groups will be charged the fees assessed by the arbitrator.
Will you assist clients in negotiations with out-of-network (OON) providers prior to the start ofarbitration?
If Anthem is handling the IDR process, we will negotiate with OON providers. However, the group will becharged any fees related to IDR.
Do you have a list of certified IDR entities?
The list of certified IDR entities is available at https://www.cms.gov/nosurprises/Help-resolve-paymentdisputes/certified-IDRE-list

12What can the client expect in regard to IDR fees and expenses?
CMS issued the following guidance on the ranges of fees that can be expected for Independent Dispute
Resolution for calendar years 2023 and 2024:
Fee Type

Appliesi for disputes
initiated between:
1/1/23- 8/2/23

Appliesii for disputes
initiated between:
8/3/23-1/21/24

Appliesiii for disputes
initiated on or after:
1/22/24

Administrative fee

$350

$50

$115

IDRE Fee

Single dispute:$200-$700
Batched dispute:$268-$298
2-20 lines: 100%*
21-50 lines: 110%
51-80 lines: 120%>80 lines: 130%

Single dispute:$200-$700
Batched dispute:$268-$298
2-20 lines: 100%*
21-50 lines: 110%
51-80 lines: 120%>80 lines: 130%

Single dispute:$375-$800
Batched dispute:$490-$1,170
Fixed fee range:$75-$250, starting withthe 26th line item

IDRE Fee Tier Batching based on the number ofline items*The percentage applies to the approved batched determination fee and increases with the amount of line items
included per batch.
IDR Administrative Fee Guidance 2023 FAQs
October 2022 Fee Guidance Calendar Year 2023
iii
IDR Process Fees Final Rule (12/21/23) Updated CIDRE Feesi

ii

Will the IDR Fee be charged to the JAA client under the claims account or as a direct charge to theclient?
The IDR Fee will be direct billed.
If the IDR Fee is billed up front and the plan sponsor is determined to be the prevailing party, would
the fee be refunded to the JAA client?
The administrative IDR fee is not refundable. It is a charge by the Federal Government to use the Federal
website and process. The Arbitrator Fee or CIDRE Fee will only be charged to the client if the provider
prevails in arbitration or if the dispute is settled before the arbitrator’s decision.
How will these fees show on the ASO client invoice?
They will be in the summary section on the invoice that lists expenses associated with Independent
Dispute Resolution.
If the IDR Fee is billed up front and the plan sponsor is determined to be the prevailing party, would
the fee be refunded to the JAA client?
The administrative IDR fee is not refundable. It is a charge by the Federal Government to use the Federal
website and process. The Arbitrator Fee or CIDRE Fee will only be charged to the client if the provider
prevails in arbitration or if the dispute is settled before the arbitrator’s decision.
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Is there a defined timeline for the Negotiation and IDR Process?
Yes, CMS defines a specified timeline for the negotiations and IDR process including a 30-business day
open negotiation period prior to IDR. See the link below for details on the timeline:
https://www.cms.gov/newsroom/fact-sheets/requirements-related-surprise-billing-part-ii-interim-final-rulecomment-period
Are CIDRE decisions appealable?
Per the NSA and implementing regulations, the decision of the CIDRE is binding on all parties except in thecase of fraud and cannot be appealed. Additionally, neither the NSA nor the implementing regulations
provide any process for challenging CIDRE jurisdiction or the decision when the CIDRE issues a decision on an
ineligible dispute. The only remedy that appears available to a group health plan who feels that a CIDRE
issued a decision on a dispute not subject to the NSA is to seek to enjoin enforcement of the CIDRE
award. However, the group health plan should contact their own legal counsel for advice.

ID Card Requirements
The CAA requires health plans to provide information on ID cards regarding the amount of the innetwork and out-of-network deductibles, the in-network and out-of-network out-of-pocket maximum
limitations, and a telephone number and Internet website address through which individuals may seek
consumer assistance information.
On August 20, 2021, the Tri-Agencies announced they will issue regulations to implement the ID card
requirements but would not do so prior to January 1, 2022. These regulations or other regulatory
guidance has not yet been issued. However, Plans and issuers are expected to implement based on agood faith, reasonable interpretation of the requirements by the January 1, 2022, compliance date.
ID cards should be issued consistent with the Anthem ID Card manual, which has been updated.

Prohibition on Gag Clauses
The CAA Gag Clause provision prohibits group health plans and health insurance issuers offering grouphealth insurance coverage from entering into an agreement between a plan or issuer and a healthcare
provider, network or association of providers, third-party administrator, or another service provider
offering access to a network of providers that would directly or indirectly restrict a plan or issuer fromdisclosing or accessing certain price and quality information.
In addition, group health plans and issuers are required annually to submit an attestation to confirm
compliance with the prohibition on gag clauses.
We are providing JAA/MCS clients and TPAs with the following confirmation of compliance, that will allow
you to complete the attestation on the CMS HIOS portal:
Anthem represents that the administrative services provided under its Administrative Services
agreements are consistent with the requirements set forth in Section 201 of the Consolidated
Appropriations Act, 2021.
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This attestation statement applies only to the business and information that we administer and maintain.
Clients need to complete the required attestation by December 31 for each year. Please reference thefollowing CMS link for submission instructions on how to complete this attestation:
https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/gag-clause-prohibitioncompliance
Anthem’s standard provider contract language and our JAA/MCS agreements include a provision statingthat the parties will comply with applicable law. Therefore, any “gag clause” in the agreements will cease
to apply as of the law’s effective date.
Have your participating provider contracts been revised to remove any language that restricts
cost information sharing except for reasonable restrictions as permitted by the CAA, to allow
plan sponsors to complete the attestation required?
Anthem’s provider contracts are administered to comply with the law, including the restrictions
placed on Gag Clauses by the CAA.

Continuity of Care
The CAA requires health plans to provide in-network coverage for 90 days of continued care to members
whose provider or facility leaves the health plan’s network when the member is undergoing treatment fora serious and complex condition, pregnant, receiving inpatient care, scheduled for non-elective surgery, or
terminally ill.
On August 20, 2021, the Tri-Agencies released FAQs noting that they will issue regulations to implement
the continuity of care requirements but will not do so prior to January 1, 2022. Plans and issuers are
expected to implement based on a good faith, reasonable interpretation of the requirements by theJanuary 1, 2022, compliance date.
Describe how you will implement the requirement to allow continuation of care for individuals when
their health care provider is terminated from the Network, under ERISA Section 718 and PHSA Section
2799A-3.
We currently have a process for notifying TPAs of providers leaving the network. The TPA or designatedentity will then notify impacted members based on their review process. The TPA will need to notify
Anthem if a member has elected continuity of care so Anthem can price the claim using in-network
reimbursement amounts. This process is contained in a document already shared with a TPA.

Pharmacy and Other Health Reporting
The Consolidated Appropriations Act requires health insurers offering group or individual healthcoverage and self-funded group health plans to report annual data to the Tri-Agencies on drug
utilization and spending trends. The reporting must include total spending on healthcare services bytype, such as for hospital, primary care, or prescription drugs. The reporting must also include rebate
information and its effect on member costs.
The required reporting templates include:
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•
•

•

Plan Lists (Individual and Student, Group Health Plan List, and FEHB Plan List)
Data Files (reporting of aggregated data based on state and market segment)o Premium and Life-Years Reportingo Spending by Category Reportingo Top 50 Most Frequent Brand Drugs Reportingo Top 50 Most Costly Drugs Reportingo Top 50 Drugs by Spending Increase Reportingo Rx Totals Reportingo Rx Rebates by Therapeutic Class Reportingo Rx Rebates for the Top 25 Drugs Reporting
Narrative Response

On August 20, 2021, the Tri-Agencies announced a delay in enforcement of the pharmacy and other
health reporting requirements until the issuance of new regulations. The new compliance date was
December 27, 2022, for reporting years 2020 and 2021. Future years reporting will be due on June 1
annually (i.e., 2023 data will be due on June 1, 2024).
An Interim Final Rule was issued on November 17, 2021, including instructions for this reporting that were
subsequently updated. Critical reporting detail continues to be provided.
According to the reporting instructions, the reports may be submitted by different entities based on
the information required in the report. For example, for a self-funded group, the Group Health Plan or
TPA may submit the Spending by Category reporting, while the PBM submits pharmacy related reports
such as the Top 50 Most Costly Drugs report.
Will Anthem complete the reporting for JAA/MCS business?
No. Please consult with your TPA and any carve-out vendors you work with for guidance regarding thereporting submission for JAA/MCS business.
Note: If the JAA group has CarelonRx (formerly IngenioRx) coverage, CarelonRx will do that filing forthe relevant portions (e.g., D3-D8) in aggregate for the data it maintains and administers. A Plan List
and narrative file will also be submitted.
Why isn’t Anthem doing the Pharmacy Reporting for JAA Groups?
There are two data file reports that are the responsibility of the health plan or its third-party
administrator – D1 and D2.
••

D1 reports the premium and life-years for the plan and its enrollees.
D2 reports plan spending by category.

The TPA’s claim system will have the most accurate and timely data for the report, so Anthem has
made the decision to defer this reporting to the TPA and not include JAA business in our reporting. A
health plan or its third-party administrator would also submit a separate Plan List and narrative filealong with these Data Sheets.
Why can’t Anthem create the D1 report?
Anthem does not maintain all of the information on its systems for this report, so the TPA would be thebetter resource. For example, the report requires information on ASO and other TPA fees. Anthem has
no insight into how much the TPA charges for its administration of the plan. Without this information
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and other information, we also cannot calculate the premium equivalent values for the plan.
Why can’t Anthem create the D2 report?
Once again, the TPA has the data required to create this report, data for which Anthem does not haveaccess. For example, calculating total spending includes claims reported within the period but still in
the process of adjustment or payment. The TPA would have more accurate knowledge of claims in theprocess of adjustment (e.g., a claim denial that has been overturned on appeal, but the adjustment not
yet been sent to Anthem). Similarly, the plan must exclude third party liabilities. We do not haveinsight into claims that the TPA may be evaluating for workers compensation or other types ofsubrogation (Anthem does not handle subrogation for most groups outside of California). We also do
not have any insight into whether the group maintains any claims reserves.

Air Ambulance Reporting
The Consolidated Appropriations Act requires group health plans and health insurance issuers to report
information about claims data for air ambulance services and such other information regarding air
ambulance services as specified by the Secretary of HHS.
The CAA also requires providers of air ambulance services to submit information regarding air
ambulance services, including air ambulance providers’ transportation and medical costs, information
on each provider’s bases and aircraft, the number of air ambulance transports by payor and otherinformation about transports, data on claims denials, and other information specified by the Secretaryof HHS.
A proposed regulation on the Air Ambulance reporting provision of the Consolidated Appropriations Act
was issued on September 16, 2021, with a request for comments/feedback.
When is the Air Ambulance Reporting due?
According to the proposed regulation, the reporting is required for two years only. Reporting for 2022
data will be due March 31, 2023, and reporting for 2023 data will be due March 31, 2024, however atthis time there is no final regulation providing the needed details for submission. It is anticipated that
this date will be moved.
How will the reporting be used?
The Secretary of HHS, in consultation with the Secretary of Transportation, will issue a comprehensive
public report summarizing the data and providing an assessment of the state and certain aspects andcharacteristics of the air ambulance market.
Will Anthem submit the reporting on behalf of clients?
Based on the proposed regulation, Anthem is moving forward with the development of the reportingwith the intent to submit the reporting on behalf of our clients, including JAA clients. We will continue
to monitor and provide any updates as additional regulatory detail is received and will advise if there isa change that impacts the approach.
Will this reporting be client specific?
No, the reporting will include all air ambulance claims for Anthem.
MCS – Please contact your TPA for information regarding the submission of Air Ambulance reporting.
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JAA Contract Language
Article 1, Consolidated Appropriations Act (“CAA”). The Consolidated Appropriations Act of 2021 (42 USC
300gg, et seq. and 29 USC 1185, et seq.), as amended, and regulations promulgated thereunder.
Article 1, Paid Claim Definition, subparagraph (4):4. Claims Payment Pursuant to any Judgment, Settlement, Legal or Administrative Proceeding. Subject to
Article 16 as applicable, Paid Claims shall include any Claim amount paid as the result of a settlement,
judgment, or legal, regulatory, or administrative proceeding brought against the Plan and/or Anthem, orotherwise agreed to by Anthem, with respect to the decisions made by Anthem regarding the coverage ofor amounts paid for services under the terms of the Plan. Paid Claims also includes any amount paid as aresult of dispute resolution procedures.
Article 2(d):Consistent with the requirements of the CAA, Anthem shall provide Members and potential Members
access to an online directory of Providers contracted with Anthem (“Provider Directories”). Additionally,
Anthem shall ensure that Members and potential Members have access to the InterPlan directory ofProviders via a website sponsored by BCBSA. Anthem grants Employer the permission to link to Anthem’s
website to allow Members to access Provider Directories and other available information, including
information needed to comply with requirements of applicable law such as posting of machine-readable
files.
Article 2(o):o. Anthem shall assist Client or its designee with compliance with the following requirements underfederal law as of the applicable effective date:
1. Include recognized amount (qualified payment amount) when transmitting surprise billing Claims
under the Agreement to enable Client to calculate Member cost sharing.
2. Notify Client or its designee in the event of Provider termination from the network forcontinuity of care administration.
3. Unless waived by the Client, Provide Member cost transparency tool access throughanthem.com for the benefits and rates administered by Anthem if listed in Schedule A
for the fee set forth in Section 3.B of Schedule A. The tool is based on data that Anthem
has for Client and is based on Anthem’s standard administration, such as processing of
preventive care Claims, and estimated out of network rate information. The estimatedout of network rate information provided through the tool is not Provider-specific and,
if Anthem does not provide utilization management services for Client, the tool will notprovide detail as to whether prior authorization is required.
4. Provide reasonable assistance to Client or its designee in generating advance explanation of
benefits upon Provider request. Administration of independent dispute resolution process
for non-Network Provider Claims (including non-network air ambulance Provider Claims)(“IDR Process”) as set forth under the Consolidated Appropriations Act as follows:a. For services in the Anthem Service Area:i. When Anthem pricing is used, Anthem will administer the IDR Process.
ii. When Anthem pricing is not used, Client is responsible for the IDR Process and,notwithstanding anything to the contrary in the Agreement, Anthem authorizes
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Client or its designee to contact Providers directly for purposes of the IDR
Process.
b. For services outside of the Anthem Service Area:i. The Host Blue or Anthem will administer the IDR Process.
ii. If Client would like to administer the IDR Process for a particular Claim, Client or
its designee will request permission, as applicable, from the Host Blue throughAnthem in advance of the negotiation and within 2 business days of receipt of thenegotiation request. If the Host Blue approves the request, Client will be
responsible for the IDR Process and, notwithstanding anything to the contrary in
the Agreement, Anthem authorizes Client or its designee to contact Providers
directly for purposes of the IDR Process.
In all cases except (a)(ii) above, Client or its designee will notify Anthem within 2 business days ofreceipt that an independent dispute resolution request has been received.
5. Upon request, provide the non-quantitative treatment limitation analysis for the standard
services that Anthem provides under the Agreement. Anthem will also provide reasonableassistance to Client in the event of a regulatory audit for compliance with the Mental HealthParity and Addiction Equity Act.
6. Post machine readable files for the services Anthem administers for the Plan on anthem.com.
Article 10(f):This Agreement shall not be construed to restrict the use or disclosure of information that: (1) ispublic knowledge other than as a result of a breach of this Agreement; (2) is independently
developed by a Party not in violation of this Agreement; (3) is made available to a Party by any
person other than the other Party, provided the source of such information is not subject to any
confidentiality obligations with respect to it; (4) is required to be disclosed pursuant to law, order,
regulation or judicial or administrative process, but only to the extent of such required disclosuresand after reasonable notice to the other Party; or (5) is required to be disclosed to a Member.
Section 3.B of Schedule A:
Member Cost Transparency Tool Access. Included in the Base Administrative Services Fee
Fees and Costs for Independent Dispute Resolution. Notwithstanding anything to the contrary in
the Agreement, Client shall assume liability for payment of all fees and costs, including but notlimited to arbitrator fees, charged to or paid by Anthem as part of independent dispute resolution
processes.

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MCS Contract Language
Article 1, Consolidated Appropriations Act (“CAA”). The Consolidated Appropriations Act of 2021 (42 USC
300gg, et seq. and 29 USC 1185, et seq.), as amended, and regulations promulgated thereunder.
A new Article 2(k):k. Anthem shall assist Client or its designee with compliance with the following requirements underfederal law as of the applicable effective date:
1. Include qualified payment amounts when transmitting surprise billing Claims under the
Agreement to enable Client to calculate Member cost sharing.
2. Notify Client or its designee in the event of Provider termination from the network forcontinuity of care administration.
3. Upon request, provide the non-quantitative treatment limitation analysis for the standard
services that Anthem provides under the Agreement. Anthem will also provide reasonableassistance to Client in the event of a regulatory audit for compliance with the Mental HealthParity and Addiction Equity Act.
4. Post machine readable files for the in-network services Anthem administers for the Plan
on anthem.com.
Article 10(e):e. This Agreement shall not be construed to restrict the use or disclosure of information that: (1) is publicknowledge other than as a result of a breach of this Agreement; (2) is independently developed by a Party
not in violation of this Agreement; (3) is made available to a Party by any person other than Anthem or
Client, provided the source of such information is not subject to any confidentiality obligations with respect
to it; or, (4) is required to be disclosed pursuant to law, order, regulation or judicial or administrative
process, but only to the extent of such required disclosures and after reasonable notice to the other Party;or (5) is required to be disclosed to a Member.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO
products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc.
In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. and Community Care Health Plan of Georgia, Inc. In Kentucky:
Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas
City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT andcertain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT andcertain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain
Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem
Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwrittenby Matthew Thornton Health Plan, Inc. In 17 southeastern counties of New York: Anthem HealthChoice Assurance, Inc. and Anthem
HealthChoice HMO, Inc. In these same counties Anthem Blue Cross and Blue Shield HP is the trade name of Anthem HP, LLC. In Ohio:
Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield, and its
affiliate HealthKeepers, Inc. trades as Anthem HealthKeepers providing HMO coverage, and their service area is all of Virginia except
for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin(BCBSWI) underwrites or administers PPO and indemnity policies and underwrites the out-of-network benefits in POS policies offeredby Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare
underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent
licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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