For Providers:
Health West Administrators hereby certifies that a.) the Qualifying Payment Amount ("QPA") applies for purposes of the recognized amount (or, in the case of air ambulance services, for calculating the enrollee's or dependent's cost-sharing), and b.) the QPA values outlined on this Explanation of Payment were determined in compliance with the No Surprises Act (NSA) and its related regulations, as are applicable.

If you have questions about this payment or wish to open negotiations in accordance with the NSA, please contact Health West Administrators by phone at 800-233-6306. You must provide the official negotiation notice to Health West Administrators within thirty (30) business days of your receipt of the initial payment or notice of denial of payment for the item or service.

If the open negotiation period does not result in a mutual agreement on the out-of-network rate, you may initiate the federal Independent Dispute Resolution ("IDR") process within four (4) business days after the end of the open negotiation period. For additional information on the NSA, please see the federal government's NSA website: https://www.cms.gov/nosurprises

For Members:
No Surprises Act EOB Disclosure