NOTICE OF PATIENT RIGHTS UNDER THE NO SURPRISES ACT

(Effective under federal law 45 C.F.R. § 149.430)

The No Surprises Act protects you from unexpected medical bills when receiving certain healthcare services, including pharmacy services. These protections apply if you are enrolled in a group health plan, individual or family health insurance coverage, or the Federal Employees Health Benefits (FEHB) Program, as well as uninsured individuals and people paying out of pocket for their pharmacy services.

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What is "Surprise Billing"? 

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A surprise bill occurs when you receive a service or prescription from an out-of-network provider without your knowledge, and you are charged more than expected. This can happen during emergency care or when receiving services at an in-network facility from an out-of-network provider. Under the No Surprises Act, you are protected from being billed more than you’re in-network cost-sharing amount (e.g., copayment, coinsurance, deductible) in certain situations. 

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You have the right to get care without surprise pharmacy bills. 

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This Act protects you from surprise balance billing in the following scenarios: 

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• Emergency care: If your medication or service is part of an emergency treatment, you can’t be charged more than your insurance plan’s in-network rate even if we are not in your insurance network. 

• Non-emergency care at an in-network location: If you get services at an in-network location (like a hospital or clinic), and someone involved in your care (like a lab or pharmacy) is out-of-network, you cannot be charged more than in-network rates unless you are notified and provide the authorization. 

• Uninsured or cash-pay patients: If you don’t have insurance or choose not to use it, you have the right to get a Good Faith Estimate in writing before we process your prescription. This estimate provides a breakdown of the prescription cost. If your final bill is $400 or more over the estimate, you may be able to dispute it. 

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What does this mean for our pharmacy? 

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Alivia Health is committed to full compliance with the No Surprises Act and all applicable federal regulations. We have implemented procedures to ensure you are informed of your rights and protected from unexpected (or “balance”) billing. As part of our commitment: 

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• We will always attempt to process your prescriptions using your insurance at in-network rates. 

• If a prescription is not covered or must be billed out-of-network, we will inform you of your options before processing the prescription.  

• You will not be charged more than your in-network cost share unless you are notified in advance and provide consent. 

• Upon request, by phone, or in writing, we can provide a Good Faith Estimate of expected charges.  

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What if you think a billing mistake was made? 

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If you identify a discrepancy on the services billed, you can contact our Revenue Cycle Management (RCM) Department by calling phone: 787-925-1989 or 1-888-925-1989.  

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Additionally, if you would like to dispute a charge, you can file a complaint with our Quality and Compliance Department: 

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Phone number: 787-709-4208 

Mail: P.O. BOX 246 Bayamón, Puerto Rico 00960 

Email: complaints@aliviahealth.com  

Website: https://www.aliviahealth.com/compliance   

Online Form:  

https://secure.compliance360.com/ext/uUDPuYkRH_qKmniO6ttBfg==   

Confidential reporting site: aliviahealth.ethicspoint.com    

Puerto Rico Confidential Hotline Number: 833-407-9028