Transparency in Coverage Regulation and Consolidated Appropriations Act
External FAQs for Fully Insured and ASO including Anthem Balanced Funding(ABF)
NOTE: For JAA/MCS clients, please refer to the JAA/MCS 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 Healthand Human 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.
The TIC regulation (Regulation) requires health insurers and group health plans (Health Plans) to makean 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
healthcare items and services, Health Plan expanded those tools to cover all items and services by
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 publicmachine-readable files (MRF) beginning on July 1, 2022 (delayed from January 1, 2022) that containthe negotiated rates with in-network providers for all covered items and services as well as historical
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
by a plan or issuer at the pharmacy location 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 is not amending its fully insured contract to reflect these laws, since there is a standard
provision stating Anthem will comply with applicable law. Anthem will be updating Certificates of
Coverage as needed, depending on state law, to inform members of their benefits under these laws.

1Anthem is amending the ASO agreement as described at the end of this FAQ to incorporate theservices Anthem will be providing under the Regulation and CAA.
What areas will Anthem take responsibility for and make updates to be in compliance?
Anthem developed an implementation strategy for achieving the Transparency requirements, theintent of which is to provide a compliant solution which applies equally to fully insured and selffunded (ASO) clients for the data 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 to the services supplied by the third-party vendor.
Will Anthem be amending par-provider contracts to allow for the disclosure of rates for the
purpose of satisfying the transparency requirements?
Anthem’s participating provider contracts permit the disclosure of proprietary information whererequired by law or regulation, but only as it relates to the scope of the specific mandate and not
beyond what is required by law.
What areas does Anthem feel are already in compliance with no change needed? Where are
the current tools relative to the requirements as they are outlined by effective dates?
While Anthem does have member transparency tools, such as Find Care in place and currently
available for much of our business, changes have been implemented based on the current
language in the Regulation. Additional rulemaking is anticipated.
Will there be a cost for hosting the platforms or providing the data?
There will be no additional charge for this specifically. However, the new regulations will be taken into
consideration when determining our administrative fees.
Will you support the employer’s communication to their employees on these changes and new
resources?
We do anticipate communicating with employers as to our implementation activities for theselaws. Employers may use these communications to develop communications for their employees.
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
for other 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 group andindividual 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 and theFederal 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 theTransparency 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. Employers 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 a third-party vendor, such as a PBM, then thegroup should work with that vendor to determine whether it is providing a similar 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
and potentially dampen the rise in health care spending.” The government expects private entities tocreate apps or websites to enable consumers to view and compare this rate information. Once again, thefiles are “machine readable,” so consumers must rely on someone with a computer program and systemcapability 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
Care to shop for health services and understand how costs differ from provider to provider.
How often will the machine-readable files be updated?
The files will be updated monthly on the first of each month.
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 you only provide your data, or will your platform allow for merging other vendor’s data
(e.g., PBM, specialty network, etc.)?
We only provide the data we administer and maintain.
Will the publicly available files be accessed through the current participant portal or be located ina new portal? Will you provide the files to plan sponsors or can plan sponsors link to the files?
These files are accessible through anthem.com on a publicly available website. Due to the size of thefiles, we will not provide the data directly to our clients. Plan sponsors may link to those files as desired.
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 incorrectly, validating results of the data from the source system pull, and validation of data as it appears in
production.
How will client-specific machine readable files be accessed on anthem.com?
Beginning July 1, 2022, and on the first of every month thereafter, Anthem will publish the machine3

readable files for the plans we administer and maintain on anthem.com 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 Employer Identification Number (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
be loaded using the group EIN.
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 Innetwork rate file on its public website on behalf of the group health plan?
Per CMS FAQ #37 published on 6/17/22 (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 byentering into a written agreement under which a service provider (such as a TPA) posts the Allowed
Amount file and the In-network Rate file on its public website on behalf of the plan. However, if a plan
enters into an agreement 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, theplan violates these disclosure requirements. The Departments intend to follow up with the issuance offormal guidance soon.
How do I know which file to pick for my product?
The JSON File naming convention will reflect the product name (e.g., PPO, HMO).
Please describe how your organization will respond to questions regarding the files.
Please contact your Account Manager for any specific questions regarding the files. Your AccountManager will ensure that the question is routed to the appropriate team for response.
Will you provide the plan with any of the three machine-readable files on a monthly basis including
in-network rates, out-of-network allowed amounts, and prescription drug negotiated rates (fordrugs dispensed under the medical plan)?
No, due to their size, 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
be reflected 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.

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Cost Transparency Tool
The Transparency in Coverage regulation (Regulation) requires health insurers and group health plans(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 negotiatedrates for 500 covered health care 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 amember to compare the amount of cost-sharing the individual would be responsible for paying under
the plan with respect to a specific item or service by a participating provider.
How will Anthem make the tool available to plan participants? Through your website, by
providing information to plans, or through another option?
The tool is available through our website. Data produced from the tool will be based on information
Anthem administers and maintains.
How will you respond to individuals who request the information on paper or by telephone insteadof through the website?
Requests for information on paper or by telephone will be handled by Member Services.

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

Requires plans to develop and make available price transparency tools, good faith estimatesand an 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 detailof this law will be determined by regulations that will be released in future rulemaking.
Anthem is working alongside other stakeholders to assess the operational complexities andtimelines for implementation and continues to make recommendations to the Tri-Agencies who
must develop these regulations.
Who does this law apply to?
All types of employer plans, including self-funded employers as well as health insurance issuers in
the individual and group markets.
What types of plans are excluded from the scope of the CAA?
• Short-Term Limited Duration plans
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•
•
•
•

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
Health Plan (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 became effective January 1, 2022.
The requirement for plans to provide a good faith estimate of charges and an Advance
Explanation of Benefits (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
do so 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.
Do the CAA and Transparency requirements have any pricing impact to premium/administrative
services fees?
At this time, we do not anticipate a direct cost to the client for standard compliance with thisprovision, except for the surprise bill/IDR process described below for our ASO clients, however the
new regulations and laws will be taken into consideration when determining our administrative feesor premium rates we charge our clients.
How will Anthem make additional quality data available to supplement/complement
the requirements – and how/when will changes occur going forward?
QA processes are an integral part of our solution designs.
Will you support the employer’s communication to their employees on these changes andnew resources?
We do anticipate communicating with employers as to our implementation activities for theselaws. Employers may use these communications to develop communications for their employees.
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
for other services will be determined once regulations are finalized.

CAA Price Comparison Tool
The CAA requires Health Plans to make available to members a price comparison tool to enable amember to compare the amount of cost-sharing the individual would be responsible for paying
under the plan with respect to a specific item or service by a participating provider.
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.
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Provider Directory
The CAA requires Health Plans to establish a verification process to confirm provider directory
information at least every 90 days and establish a procedure to remove providers or facilities who are
non-responsive. Health 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 beliable 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 based ona good faith, reasonable interpretation of the requirements by the January 1, 2022, compliance date witha 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. Anthem ismoving forward with a focus on good faith compliance while awaiting additional regulatory guidance.
Will a provider directory be available and kept up to date?
Yes.
Will directory be available electronically and/or printed?
Yes.
For your ASO clients, will you accept responsibility for directory inaccuracies resulting in added plancost?
The Administrative Services Agreement’s indemnification provision will apply.
Will you comply with the provider directory requirements on behalf of your employer clients?
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 fromthe final regulations.
Will you notify employers of the update?
No.
Will the versions be dated, so employers will know the updates are current?
Those processes will be determined as a part of our design based on implementation guidance fromthe final regulations.
How will access to the directory be provided (i.e., directly or via an employer 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 CAA were several measures intended to strengthen parity in MH/SUD benefits,
specifically with Non-Quantitative Treatment Limitations (NQTLs). Importantly, if a group health planthat provides both Medical/Surgical (MS) benefits and MH/SUD benefits and imposes NQTLs on
MH/SUD benefits, the plan has to perform testing and make testing results available to the TriAgencies, or any state authority, upon request within 45 days of enactment of the CAA (generally, no
later than February 10, 2021). Plans must also document and make available 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 and apply the NQTLs to MH/SUD benefits and MS benefits.
4. The comparative analyses demonstrating that the processes, strategies, evidentiarystandards, and other factors used to apply the NQTLs to MH/SUD benefits, as written and inoperation, are comparable to, and are applied no more stringently than, the processes,
strategies, evidentiary standards, 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 healthinsurance 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 incompliance.
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 on these new requirements.
What is a Non-Quantitative Treatment Limitation (NQTL)?
Mental Health Parity law looks at two types of treatment limitations – quantitative and nonquantitative. Quantitative treatment limitations are the limits that apply to the coverage in thebenefit booklets, such as cost-sharing and visit limits. Non-quantitative treatment limitations arebehind-the-scenes administrative activities that take place but may impact coverage. Examples
include credentialing, how Health Plans determine the amounts to pay providers, utilization
management, creation of medical policies and case management. The law requires that Health Plans
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 employers, as well as healthinsurance issuers in the individual and group markets. The only commercial products that are notaffected are small group grandmothered and grandfathered plans. It does not apply to mostMedicare plans or retiree-only group plans.
8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.
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 Anthem utilizes its standard policies and procedures. Anthem has
used the 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
self-insured grouped?
The NQTL analysis applies to all fully insured business. To the extent a self-funded grouputilizes Anthem’s standard processes and procedures for the administration of its Health 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 authorizationlist) or doesn’t use Anthem as a vendor for all of its plan administration (e.g., Pharmacy), thenNQTL analysis would be the responsibility of the group or its other vendor(s).
Will Anthem provide required documentation for ASO clients?
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
the group’s responsibility (e.g., benefit exclusions, Pharmacy with a non-Anthem vendor, etc.).
Will Anthem perform the NQTL test for ASO groups?
If a group uses our standard policies and procedures, our existing NQTL analysis will apply to themand no group-specific testing is needed. For other NQTLs that are solely within the group’s control(e.g., benefit design) or a requested deviation from our standard process (e.g., change topreauthorization 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 carved out pharmacy services, then the group will need to work with thatvendor 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), andTreasury (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 issubject to change. Current regulations remain in place, and Anthem continues to operate to demonstratecompliance in accordance with these requirements.
9Regardless of the proposal and its impact, Anthem recognizes the importance of mental health andsubstance abuse services and remain committed to ensuring our clients and members have access tosuch services and care.

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
to provide treatment, the network status of those providers, good faith estimates of cost, cost-sharing
and progress towards meeting deductibles and out-of-pocket maximums, as well as whether a service
is subject 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.

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 inlimited 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 are still to bereleased and may be impacted by various court cases. The information provided below incorporates
the regulations that were issued on July 1, 2021, and September 30, 2021. On August 19, 2022, the
Tri-Agencies 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, for good 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.
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(HCPCS), or Diagnosis-Related Group (DRG) Code. Given the requirement that a separate QPA be
established for each Service Code, Revenue Codes may also be considered Service Codes under theoutpatient methodology. Based on a Final Rule published in August 2022, Anthem is aligning with thecalculation of separate median contracted rates by provider specialty both in instances where its
10contracting process sets different rates for specialties and where the contracting process results indifferent rates for different specialties.
How will member cost sharing be determined for use of out-of-network providers/facilities
when surprise billing criteria is met?
Anthem will use the QPA to determine the member cost share. Member cost share will be based on
the lower of the QPA or provider billed charge.
Does the No Surprises Act apply to ground ambulance as well as air ambulance?
No, the law applies only to air ambulance.
The CAA will require health plans to reimburse out-of-network (OON) providers and facilities inthe situations where balance billing is prohibited. Will Anthem be offering services to support
this?
Yes, Anthem is prepared to pay the provider directly where applicable.
Are there any state laws that affect your determination of the recognized amount? If so,please describe.
State surprise billing laws will continue to apply to the state’s fully insured business and insituations where ASO groups have opted-in to the state law. The Federal “No Surprises Act” will
apply to self-funded business and fully insured business in states where there are no surprisebilling laws.
How will negotiation and arbitration be handled?
We will negotiate with OON providers for our ASO and fully insured clients. However, an ASO groupwill be charged any fees related to IDR arbitration. This chargeback is not applicable to fully insured
clients.
Will your organization handle arbitrations with out-of-network providers that do not accept theplan’s out-of-network rate?
Yes, however for ASO clients, there will be a chargeback to the client for the IDR fees. This chargeback is
not applicable to fully insured clients.
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
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
ini�ated between:
1/1/23- 8/2/23

Appliesii or disputes
ini�ated between:
8/3/23-1/21/24

Appliesiii or disputes
ini�ated on or a�er
1/22/24

Administra�ve fee
IDRE Fee$350
Single dispute:$200-$700$50Single dispute:$200-$700$115
Single dispute:$375-$800
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IDRE Fee Tier Batching based on the number ofline items

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

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

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

*The percentage applies to the approved batched determination fee and increases with the amount of line items
included per batch.
IDR Administra�ve 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 ASO 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 ASO client?
The administrative IDR fee is not refundable. It is a charge by the Federal Government to use theFederal website and process. The Arbitrator Fee or CIDRE Fee will only be charged to the client if theprovider 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.
What type of reporting on IDR cases will be available to ASO clients?
We will provide reporting when requested. We are considering other types of reporting in the future
and welcome our clients’ input on what information would be valuable.
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-interimfinal-rule-comment-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 its own legal counsel for advice.
Will you post the required disclosure notice on your website and include it on Surprise Bill member
Explanation of Benefits (EOBs) beginning 1/1/22?
Yes. We posted a notice to our site that will meet the mandated requirements and will also be included
with applicable Explanation of Benefits (EOBs) beginning 1/1/22. The client can choose to link to our
12notice. In regard to an ASO client, each entity is responsible for posting on their site as they deem
appropriate.
Where on the public site will the model notice be placed?
The notices have been posted at the following website: www.anthem.com/no-surprise-billing

ID Card Requirements
The CAA requires health plans to provide information on ID cards in a clear and understandable
manner regarding the amount of the in-network and out-of-network deductibles, the in-network andout-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.
The Tri-Agencies advised they were aware of the challenges for the plans with complex benefit
structures, and provided elements to determine compliance, including the usage of a website where
information was not included on the face of the ID card.
Will ID cards be able to include INN/OON deductibles and OOP limits?
Anthem added verbiage to member ID cards advising the member where they can retrieve helpful,easy to understand information regarding their benefits. This information will include up to date inand out-of-network deductibles and out-of-pocket maximums.
Will ID cards be able to include provider directory contact info?
ID cards currently include a telephone number and Internet website address through which an individual
may seek consumer assistance information, such as information related to providers that are
participating in their network.
When do you need renewal decisions in order to produce new cards in a timely fashion?
Anthem will make the required changes to any impacted ID cards that we issue with effective dates
from January 1, 2022, and forward. ID cards will continue to be issued when required (e.g., anychanges necessitating reissuance). For any needed reissuance for plan years on or after January 1,
2022, the changes were be incorporated in our administrative fees.
Given the new guidelines to display in-network (INN) and out-of-network (OON) cost-sharing
requirements, we presume the new ID cards need to be issued. Please confirm Anthem’s ability
to support this and expected timing.
Anthem will include a message directing the member to anthem.com for detailed benefit informationthat provides INN/OON cost-sharing requirements. We will make the required changes to any
impacted ID cards that we issue with effective dates from January 1, 2022, and forward. ID cards willcontinue to be issued when required (e.g., any changes necessitating reissuance). For any neededreissuance for plan years on or after January 1, 2022, the changes were incorporated.

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CAA Pharmacy and Other Health Reporting
The Consolidated Appropriations Act requires health insurers offering group or individual healthcoverage and self-funded (ASO) 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:• 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 reporting
requirements until the issuance of new regulations. The new compliance date is December 27, 2022,
for reporting years 2020 and 2021. Future years reporting will be due on June 1 annually (i.e., 2022
data will be due on June 1, 2023).
An Interim Final Rule was issued on November 17, 2021, including instructions for this reporting thatwere subsequently updated. We will continue to work with CMS and other impacted stakeholders tomake recommendations to the Tri-Agencies in areas where the reporting requirements are unclear
or reporting includes data that is not maintained by issuers.
Please refer to separate communication from Anthem and notes below regarding future years
reporting.
NOTE: For JAA/MCS clients, please refer to the JAA/MCS FAQ document.
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 TPA or Medical
Issuer 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 submit the reporting to HHS?
ASO groups or their delegates will be responsible for the filing of the D1 Premium and Life Years Report.
This will also require the submission of a corresponding Plan Report by the ASO group.
Alternatively, Anthem offers an opt in option to ASO groups for Anthem to submit the D1 file for data
Anthem administers and maintains.
•

What is Anthem submitting by default?
o Anthem will continue to complete the following reporting on behalf of ASO and FI clients:
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P2 – Group Health Plan List
D2 – Spending by Category Reporting (included in aggregate submission for thebusiness we administer and maintain) Narrative Response applicable to the Anthem businessWe will continue to file the D1 reporting for Fully Insured Groups, Anthem Balanced
Funding Small Group ASO Groups, and Small Group MEWAs in OH, MO, KY, IN, and GA.
For the June 1 annual submission of prior year data, ASO groups will be given an opt-in
option if they want Anthem to submit the D1 report on their behalf for the business weadminister and maintain.
For clients that have integrated pharmacy coverage through CarelonRx (formerly
IngenioRx), we will also submit the aggregated data in the D3 – D8 Pharmacy specificreports.
If a client has a third-party or carveout vendor for any portion of the required data (e.g.,carveout PBM, Stop Loss carrier), the client should work with the carveout vendor toensure submission of that data. When prompted, the carveout vendor should select thevalue “group by same TPA” when submitting the D1.



o
o
o
o

•

How will Anthem aggregate data?
o We will submit at the Issuer/TPA level. While information on the Data Sheet (ex. D2) isaggregated at the state and market segment level, the filing will be submitted using the name
Anthem company legal name/associated EIN in the fully insured contract or ASO agreement.

Exceptions:
We will continue to file the D1 reporting for Fully Insured Groups, Anthem Balanced Funding Small GroupASO Groups, and Small Group MEWAs in OH, MO, KY, IN, and GA leveraging the survey responses collected
to calculate the aggregated averages required for the reporting. In the future, we plan to collect this data
as a part of our enrollment and renewal processes.
For the June 1 annual submission of prior year data, ASO groups will be given an opt-in option if theywanted Anthem to submit the D1 report on their behalf for the business we administer and maintain. A
survey will be sent for groups that wanted to opt-in so that they could provide information. The final due
date to complete the opt-in survey will be communicated.
Why does Anthem offer a D-1 report opt-in for ASO clients?
In order to obtain all of the required information to file one consolidated D1 report, Anthem would have tocollect, store, and report data from clients and third-party vendors. This presents concerns as thisreporting includes financial and competitively sensitive data.
The Interim Final rule continues to evolve. In many cases, our ASO clients use one or more third-parties or
carveout vendors to support their business including, but not limited to, PBMs, Behavioral Health vendors,
and Stop Loss carriers.
In addition, the D1 reporting includes other data elements such as the employer and employee premium
contribution which we do not currently collect and maintain. The safe harbor regarding reporting of noncollected member and employer contributions on the D1 report expired after the December 27, 2022,
reporting.
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How will Minimum Premium groups be considered?
Minimum Premium will be considered as fully insured for the purpose of this regulation; therefore we willcontinue to complete the D1 report filing for Minimum Premium groups.
If as an ASO group I choose to file my own D1 reporting, where can I find information about therequired filing?
You can find information regarding the filing requirements at the following CMS site:
https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/Prescription-DrugData-Collection
Below are additional details on reporting materials and HIOS portal registration that may be helpful to you
and your organization. All the information you need is on the CMS website.
CMS Materials for RxDC Reporting
On the CMS website, you can find information on current materials related to the Prescription Drug Data
Collection (RxDC) reporting along with instructions and FAQs on how to complete the submission.
Available resources include:••

Reporting instructions along with reference guides and forms needed for submission.
RxDC templates that contain the Plan List (P2) and Data Sheet (D1).

Register for HIOS Portal
The HIOS Portal User Manual PDF provides instructions on obtaining access for your organization’s filing.
The HIOS Portal RxDC Quick Reference Guide PDF explains the file submission and upload process. Bothcan be found on the CMS website, in the HIOS Manuals section. Use these resources to help you register
for HIOS Portal access and to complete your P2 and D1 reporting submissions by June 1 annually.
• Register as your organization (not as associated carrier, TPA, or PBM) by entering the contact
information of the point person from your company.
• Request the role as RxDC submitter by entering the contact information for a second person fromyour company (a different person than who completed the initial registration).
• Check the status of the RxDC submitter role when logged in.
• Upload your organizations’ RxDC submissions prior to annual due date. This is currently June 1 but
is subject to change based on CMS guidance.
• View the upload status and fix any errors during the upload process.
• Retain your confirmation number once your submission is complete.
• Contact CMS Help Desk for questions or if help is needed.
It’s important that you and your organization stay up to date on reporting guidance from CMS.
Once registered via the HIOS portal, you’ll be able to keep current on available materials and filing
requirements by attending CMS webinars or using other on-demand resources designed to help you stay
informed. Prior to the submission date, CMS may offer alternative ways to submit a Plan List and Data
Sheet by an employer.
If you want to receive an email when the RxDC resources are updated, create a Registration for Technical
Assistance Portal (REGTAP) account at https://regtap.cms.gov. Select the checkbox "Please send me
updates for the Consolidated Appropriations Act / No Surprises Act" in your account settings.
REGTAP serves as a centralized information portal for the CMS resources and training related to the16Affordable Care Act Health Insurance Marketplaces, the Consolidated Appropriations Act, 2021 (CAA)
including the No Surprises Act and other CMS policies. Registered users can access a library of resources,
search FAQs, view Computer Based Trainings, submit inquiries, and register for training events.
Will you submit the data individually by client?
No, according to the instructions, issuers are to submit the report in aggregate (combining all data)
for each reporting entity and market segment. For example, a reporting entity such as a medical
issuer that is submitting the Spending by Category report, would aggregate all of the data for eachapplicable market segment.
Will there be a cost for completing the reporting?
At this time, there will be no additional charge for this reporting specifically; however, the new regulations
will be taken into consideration when determining our administrative fee.
How will Anthem provide notification in writing that they will complete this reporting on behalf of theclient?
For self-funded groups, beginning with November 1, 2022, renewals, Anthem will add language to Section
B of its ASO Agreement to document the reporting that will be completed on behalf of an ASO client.
For our fully insured policyholders, the notice we previously provided serves as our agreement tocomplete this reporting on the client’s behalf for the benefits we administer and maintain.
How will the data be aggregated?
The reporting will be aggregated by Anthem Company, State, and Market Segment. Anthem will report thebusiness under the state/company where the policy or plan was written. This is the same legal entity thatis included in the fully insured group contract or ASO agreement.
The reports will include client data, but the reporting will not be client specific. The clients included in thereporting will be identified in the required plan reports.
The P2 report requires a Form 5500 Number. What is this number?
The 5500 Plan ID is a 3-digit number that designates one plan from another for the IRS and Department ofLabor (DOL). These numbers are to begin with 501 for a company’s first health & welfare plan.
Will all groups have a Form 5500 Number?
No. Any plan sponsored or maintained by an employer to provide benefits to employees or former
employees and their covered dependents is an ERISA plan. All ERISA plans are required to have a 5500 Plan
ID regardless of the size of the plan. Plans established by any government, government agency,municipality, or church plan would not be considered an ERISA plan and would not have a form 5500
number.
How will Anthem identify the Form 5500 Number included in the Plan reporting?
For the initial reporting year, we used the Department of Labor Form 5500 search functionality:
https://www.efast.dol.gov/5500search/. We used a combination of client survey response and theDepartment of Labor Form 5500 search functionality: https://www.efast.dol.gov/5500search/ topopulate the Form 5500 Plan ID. We plan to request this data as a part of our enrollment and renewal
processes in the future.
For clients that had coverage with Anthem during the reporting period, but have termed, will Anthem
include the data for the time period in which the client was active in their aggregate reporting?
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Yes, Anthem will include the client’s data in our aggregate reporting for the time period in which the client
was covered.
Will clients be informed when the reporting has been submitted?
Anthem will communicate to clients once aggregate reporting is submitted.
Where are the reports to be submitted?
Reports are to be submitted to HHS through their Health Insurance and Oversight (HIOS) system.
HIOS is an application within the CMS Enterprise Portal https://portal.cms.gov/portal/.

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.
For fully insured, Anthem Balanced Funding, and MEWA groups, we will complete the annual attestation
on your behalf for the business and information that we administer and maintain.
If you have a third-party or carveout vendor for any portion of the required data requiring attestation (e.g.,carveout PBM) please work with the carveout vendor on the approach for attesting their data. Reference
the following 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
For ASO groups, we will complete the annual attestation (starting with the attestation due by December
31, 2024) on your behalf for the business and information that we administer and maintain. (We will nolonger distribute an opt-in survey).
If you have a third-party or carveout vendor for any portion of the required data requiring attestation (e.g.,carveout PBM) please work with the carveout vendor on the approach for attesting their data. Reference
the following 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
For the 2023 attestation requirement, Anthem submitted the attestation on our ASO client’s behalf
upon request for the business and information we administer and maintain.
Will Anthem include the attestation for third party vendors (a vendor hired by the employer toadminister specific benefits such as Pharmacy or Behavioral Health) as a part of their attestation?
No, Anthem will only attest for the business and information we administer and maintain.
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If I have pharmacy coverage through CarelonRx integrated with my Anthem plan, will Anthem
include the pharmacy coverage as a part of their attestation?
Yes, Anthem will attest to compliance with the gag clause prohibition for pharmacy coverage that isa part of your Anthem plan.
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. Anthem will be attesting that its provider contracts are incompliance with the Gag Clause restrictions.
Will Anthem offer the same process to complete the 2024 calendar year Gag Clause attestation?
For fully insured, Anthem Balanced Funding, and MEWA groups, we will complete the annual attestation
on your behalf for the business and information that we administer and maintain. For ASO groups, startingwith the attestation due by December 31, 2024, we will complete the annual attestation on your behalf forthe business and information that we administer and maintain.

Continuity of Care
The CAA requires Health Plans to provide in-network coverage for 90 days of continued care tomembers whose provider or facility leaves the health plan’s network when the member isundergoing treatment for a 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. Anthem has moved forward with a focus on that good faith complianceincluding enhancing the current process in which a member receives notice when a provider they haveseen in the past year leaves the Anthem network. We will continue to monitor for additional regulatory
guidance.
Anthem will notify a member if a provider they see regularly leaves the health plan’s network. The
communication will advise the member of the qualifications in which they may be eligible for continued
care at in-network rates for a limited time period. Members who are undergoing treatment for a serious
and complex condition, pregnant, receiving inpatient care, scheduled for non-elective surgery, or
terminally ill would be eligible. If a member believes they are eligible based on the criteria outlined in thecommunication, they are guided to contact member services for confirmation of eligibility and to initiate
the continued care under in-network rates where approved.
If a fully insured group terminates with Anthem, members that are seeing a provider regularly will receive
notification from Anthem which will advise the member of the qualifications in which they may be eligible
for continued care at in-network rates for a limited time period. Members who are undergoing treatment
for a serious and complex condition, pregnant, receiving inpatient care, scheduled for non-elective surgery,or terminally ill would be eligible if the provider would not be in-network under their new plan. If amember believes they are eligible based on the criteria outlined in the communication, they are guided tocontact member services for confirmation of eligibility and to initiate the continued care under in-network
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rates where approved.
How will state mandates apply for Continuity of Care?
State Continuity of Care mandates may be different than Federal and will also be considered as applicablefor the determination of continuity of care. Please contact the number on the back of your ID card for any
questions regarding the specific state and Federal qualifications.
Does a Do Not Contact provision in a contract prevent Continuity of Care letters from being generated topotentially impacted members?
No, Federally mandated communications are required to be sent regardless of any Do Not Contact
contract provisions.

State All Claims Payer Databases
Please share Elevance Health and its affiliated health plans’ intention to comply with the Secretaryof Labor’s standardized reporting format for voluntary reporting to State All Payer Claims
Databases. Please comment on your expected timing according with the new regulations. Pleasedelineate the impact, if any, on the administrative fees as a result of these changes.
We currently have plans in multiple states with All Payer Claims Databases (APCD) existing or in
implementation phases (e.g., California, Connecticut, Indiana, Georgia, Maine, New York, New
Hampshire, Virginia). Elevance Health and its affiliated health plans submit data pursuant to eachstate’s requirements. Additionally, Elevance Health and its affiliated health plans intend to submit data
to any other states creating an APCD and utilize the standard format where applicable. Specificinformation regarding satisfaction of this requirement, including additional costs, is unavailable at thistime as the format and state adoption is currently unknown.

Air Ambulance Reporting
The Consolidated Appropriations Act requires group health plans and health insurance issuers toreport 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
Secretary of 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. While theproposed regulation indicated a March 31, 2023, initial filing date, at this time there is no final
regulation providing the needed details for submission. The CAA statute does not require submission
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of this reporting until a final regulation is issued.
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?
Anthem is moving forward with the development of the reporting based on the proposed regulation
with the intent to submit the reporting on behalf of our Fully Insured and ASO Clients for the claims
we administer. We will continue to monitor and provide updates as additional regulatory detail isreceived.
Will this reporting be client specific?
No, the reporting will include all air ambulance claims for the Anthem company.

Agent/Broker Disclosures
Included as a part of the CAA were provisions related to Broker and Consultant Compensation disclosureand reporting. These provisions require brokers and consultants to disclose to group health plan sponsors
any direct or indirect compensation they receive for brokerage services or consulting. For individual
health insurance coverage and short-term limited-duration insurance coverage, a health insurance issuer
must disclose to enrollees, and report to the Dept of Health and Human Services (HHS), any direct orindirect compensation that the issuer pays to an agent or broker associated with the plan section andenrolling individuals in the coverage.
Who is responsible for disclosure and reporting of the compensation?
For group business, the Broker or Consultant (including their affiliates and subcontractors) is responsiblefor disclosure and reporting. For individual business and short-term limited-duration business, the insurer
is responsible for disclosure and reporting.
A proposed regulation specific to the requirements for disclosing and reporting Agent/Broker
compensation for individual and short-term limited-duration business was issued on September 16,
2021, with a request for comments and feedback. Anthem has provided feedback on the proposed
regulations to CMS and is developing the individual and short-term limited-duration businesscompensation disclosure based on the proposed regulation guidelines. The CAA statute does not
require submission of this reporting until a final regulation is issued.

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ASO Agreement
Article 1, Consolidated Appropriations Act (“CAA”). The Consolidated Appropriations Act of 2021 (42USC 300gg, et seq. and 29 USC 1185, et seq.), as amended, and regulations promulgated thereunder.
Article 1, Paid Claim Definition, subparagraph (5):5. 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,or otherwise agreed to by Anthem, with respect to the decisions made by Anthem regarding thecoverage of or amounts paid for services under the terms of the Plan. Paid Claims also includes any
amount paid as a result of dispute resolution procedures.
Article 2(b)(4):
4. Administration of independent dispute resolution process for non-Network Provider Claims(including non-network air ambulance Provider Claims) as set forth under the CAA or, if applicable,
through state law with Employer election as required, for the fee set forth in Section 3.C of Schedule
A. Employer agrees to promptly notify Anthem if an independent dispute resolution request is
received. Failure to promptly notify Anthem may impact independent dispute resolution process.
Article 2(aa):aa. Anthem shall provide reporting as indicated in Schedule B to assist with compliance under
the CAA.
Article 10(f):f. This Agreement shall not be construed to restrict the use or disclosure of information that: (1)is public 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
disclosures and after reasonable notice to the other Party; or (5) is required to be disclosed to a
Member.
Section 3.C of Schedule A:
Fees and Costs for Independent Dispute Resolution. Notwithstanding anything to the contrary in theAgreement, Employer shall assume liability for payment of all fees and costs, including but not limited
to arbitrator fees, charged to or paid by Anthem as part of independent dispute resolution processes.
Schedule B:
Other Services Required by Federal Law not Otherwise Specified in the Agreement (as of the applicable22

effective date):
•

•
•
•
•
•
•
•

•

For Claims that qualify as no surprises Claims, Anthem shall calculate and apply the Member’s costshare at the in-network benefit level using the qualifying payment amount. Anthem shall post a
disclosure of the patient protections against balance billing on anthem.com and shall include
applicable language in Claim denial notices and explanations of benefits.
Prepare advanced explanations of benefits to Members after receiving notice of scheduled
services from a Provider
Provide cost transparency tool/self-service access
Provide for continuity of care administration for Provider termination from the network
Provide air ambulance Provider reporting
Provide aggregated reporting as required under Section 204 of the CAA for the services that
Anthem administers under the Agreement. This reporting does not include the D1 Premium andLife Years report.
Anthem represents that it is administering its Provider agreements consistent with therequirements set forth in Section 201 of the CAA. Anthem will provide a statement of complianceto Employer pertaining to Section 201 of the CAA on an annual basis.
Upon request, Anthem will provide the non-quantitative treatment limitation analysis for the
standard services that Anthem provides under the Agreement. Anthem will also provide
reasonable assistance to Employer in the event of a regulatory audit for compliance with the
Mental Health Parity and Addiction Equity Act.
Post machine readable files on a monthly basis for the services Anthem administers for the Plan on
anthem.com.

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 and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by
HMO Missouri, Inc. RIT and certain 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 HealthPlans of New Hampshire, Inc. and underwritten by 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 areaeast 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 offered by 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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