Forms & Documents

HIPAA Authorization
No Surprises Act

Udelhoven Oilfield System Services (UOSS) Health Plan 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 UOSS Health Plan by email at, or by phone at (833) 633-8677. You must provide the notice to UOSS Health Plan within thirty (30) business days of your receipt of the initial payment or notice of denial of payment from UOSS Health Plan 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: