What Is the No Surprises Act? Insurance Term Explained

The No Surprises Act is a federal law (effective January 1, 2022) that protects patients from surprise medical bills — unexpected charges that arise when you receive care from out-of-network providers in situations you could not control or reasonably anticipate. Before this law, patients frequently received enormous bills from out-of-network doctors they never chose, particularly for emergency care and services at in-network hospitals where some providers (anesthesiologists, radiologists, pathologists) were out of network. The No Surprises Act eliminates most of these surprise bills and limits your cost-sharing to in-network amounts.

Definition

The No Surprises Act protects patients in three key situations:

1. Emergency services at any facility: When you seek emergency care, you cannot be charged more than your in-network cost-sharing amount, regardless of whether the hospital or emergency physician is in your insurer's network. This applies to all emergency services, including post-stabilization care until you can safely be transferred to an in-network facility.

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2. Non-emergency services from out-of-network providers at in-network facilities: When you receive care at an in-network hospital or surgical center, any out-of-network providers who treat you (such as anesthesiologists, radiologists, pathologists, or assistant surgeons) cannot bill you more than your in-network cost-sharing amount — unless you gave informed written consent to out-of-network billing at least 72 hours before the service.

3. Air ambulance services: Out-of-network air ambulance providers cannot balance bill you. You owe only your in-network cost-sharing amount. (Note: ground ambulance services are not currently covered by the No Surprises Act, though a federal advisory committee is studying this gap.)

Common Reasons for No Surprises Act Violations

Despite the law being in effect since 2022, violations continue to occur:

• Providers still sending balance bills: Some out-of-network providers continue to bill patients for the difference between their charge and the insurer's payment, which is prohibited in covered situations.
• Insurers applying out-of-network cost-sharing: Some insurers continue to process covered services using out-of-network deductibles, coinsurance, and copays when in-network rates should apply.
• Invalid consent forms: Some providers present "consent to balance bill" forms that do not meet the Act's requirements — for example, presenting them in the emergency department (consent is not valid for emergency services) or presenting them for provider types that cannot request consent waivers (such as anesthesiologists and radiologists).
• Post-stabilization care billing: After emergency stabilization, the rules about when a patient can be transferred and when out-of-network billing becomes permissible are complex. Some providers attempt to bill at out-of-network rates before the patient could safely be transferred or before informed consent was validly obtained.
• Cost-sharing not credited to in-network accumulator: When you receive covered emergency or involuntary out-of-network services, the cost-sharing you pay should count toward your in-network out-of-pocket maximum. Some insurers fail to credit these amounts correctly.

How to Appeal a No Surprises Act Violation

1. Identify whether the No Surprises Act applies. Check whether your situation falls into one of the three covered categories: emergency services, out-of-network providers at in-network facilities without valid consent, or air ambulance services.
2. Contact both the provider and the insurer. Notify both parties that the bill violates the No Surprises Act. Reference the specific provision and state that you will file complaints if the issue is not resolved.
3. File a complaint with CMS. The Centers for Medicare and Medicaid Services enforces the No Surprises Act for most private insurance plans. File at cms.gov/nosurprises/consumers or call the No Surprises Help Desk at 1-800-985-3059.
4. File a complaint with your state insurance department. Many states also enforce No Surprises Act provisions and may have their own surprise billing laws that provide additional protections. Find your state DOI at the NAIC directory.
5. Request a Good Faith Estimate if you are uninsured or self-pay. The No Surprises Act requires providers to give uninsured and self-pay patients a Good Faith Estimate of expected charges before scheduled services. If the actual bill exceeds the estimate by $400 or more, you can dispute it through a patient-provider dispute resolution process.
6. File a formal appeal with your insurer if they processed the claim using out-of-network cost-sharing. Your appeal letter should cite the No Surprises Act, identify the specific provision that applies, and request reprocessing at in-network rates.

What Regulations Protect You

• No Surprises Act (Public Law 116-260, Division BB, Title I): The core federal law prohibiting surprise billing in emergency and involuntary out-of-network situations
• Implementing regulations (45 CFR Parts 149 and 150): Detailed regulations from CMS, DOL, and HHS implementing the Act's requirements, including the independent dispute resolution (IDR) process between providers and insurers
• ACA provisions: The ACA's emergency services protections (requiring coverage of emergency services regardless of network status) work in conjunction with the No Surprises Act
• State surprise billing laws: Over 30 states had enacted their own surprise billing protections before the federal law. State laws may provide additional protections — for example, covering ground ambulance services, which are not covered by the federal Act.
• IDR process: The No Surprises Act established an Independent Dispute Resolution process where providers and insurers resolve payment disputes. Patients are not involved in this process and are protected regardless of its outcome.

Tips for a Stronger Appeal

• Keep every bill and EOB. Compare what the provider billed, what the insurer paid, and what you are being asked to pay. If your cost-sharing exceeds what you would have owed for an in-network service, the No Surprises Act may be violated.
• Do not sign consent-to-balance-bill forms in the ER. Consent to out-of-network billing is not valid for emergency services under any circumstances. If a provider presented such a form during an emergency, it is unenforceable.
• Verify that cost-sharing counts toward your in-network OOP max. When you pay cost-sharing for services covered by the No Surprises Act, those amounts must count toward your in-network deductible and out-of-pocket maximum, not your out-of-network accumulators.
• Report violations even if the amount is small. CMS uses complaint data to identify providers and insurers that systematically violate the Act. Your complaint helps protect other patients and may trigger enforcement action.

If you have received a surprise medical bill or your insurer applied out-of-network cost-sharing to a covered service, start your free claim analysis with ClaimBack. We generate a professional appeal letter citing the No Surprises Act and requesting proper reprocessing of your claim.

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• How to Use the No Surprises Act to Fight Unexpected Medical Bills
• The No Surprises Act: What It Means for Your Medical Bills
• No Surprises Act 2025: Everything You Need to Know
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