You went to the ER and got a $15,000 bill because the hospital was "out of network." Or an out-of-network anesthesiologist showed up during your surgery. Federal law is on your side.
Appeal My OON Denial →Takes 3 minutes · No login required · Cite federal protections
The No Surprises Act (effective January 1, 2022) is the most significant federal protection against out-of-network billing in US history. Here's what it covers.
You cannot be charged more than in-network cost-sharing for emergency services — regardless of whether the facility or providers are in your network. This applies to emergency room visits, stabilization, and post-stabilization care until you can safely be transferred. The insurer must cover these at in-network rates.
If you go to an in-network hospital or surgery center but are treated by an out-of-network provider you didn't choose (like an anesthesiologist, pathologist, radiologist, or assistant surgeon), you're protected. You only pay in-network cost-sharing, and the provider cannot balance bill you for the difference.
Air ambulance services from out-of-network providers are covered at in-network cost-sharing rates. You cannot be balance billed by the air ambulance provider. This protection applies even for non-emergency air transport when the air ambulance provider is out of network.
The only exception: if you receive written notice at least 72 hours before a scheduled service (or 3 hours before in some cases) that the provider is out of network, and you sign a consent form agreeing to out-of-network rates, the No Surprises Act protections may not apply. Emergency care can never require this consent.
Emergency care has the strongest protections. If you were denied for an emergency visit, you likely have grounds to appeal.
Federal law uses the "prudent layperson" standard for emergencies: if a reasonable person would believe the symptoms required immediate medical attention, it qualifies as an emergency — regardless of the final diagnosis. Chest pain that turns out to be heartburn is still an emergency visit because a reasonable person would seek care for chest pain.
Insurers cannot require prior authorization for emergency services. If your emergency claim was denied for lack of prior auth, this is a clear violation. Emergency care must be covered without pre-approval, and this applies to both in-network and out-of-network emergency facilities.
After you're stabilized in the ER, the No Surprises Act continues to protect you until you can safely be transferred to an in-network facility, or until you give informed consent to continue care at the out-of-network facility. Insurers cannot retroactively deny stabilization or post-stabilization care.
Many states have emergency care laws that go beyond federal protections. Some states prohibit insurers from denying ER claims entirely based on the final diagnosis, require coverage of all ER visits meeting the prudent layperson standard, and impose penalties on insurers that improperly deny emergency claims.
If you received a surprise bill, here's how the law protects you — and what to do about it.
In protected situations, out-of-network providers cannot bill you for the difference between their charge and what insurance paid. If you receive a balance bill for emergency care or non-consent OON services at an in-network facility, do not pay it. File a complaint with CMS at 1-800-985-3059 or your state insurance department.
Under the No Surprises Act, healthcare providers must give uninsured or self-pay patients a Good Faith Estimate of costs before scheduled services. If the final bill exceeds the estimate by $400 or more, you can dispute it through the Patient-Provider Dispute Resolution process.
When providers and insurers disagree on payment for protected services, the dispute goes to an Independent Dispute Resolution (IDR) process — not to your bill. An independent arbitrator decides the payment amount. You are not responsible for the disputed amount beyond your in-network cost-sharing.
If you receive a surprise bill in a protected situation, file a complaint with CMS (1-800-985-3059), your state insurance department, and the provider's billing department citing the No Surprises Act. Keep copies of all bills, EOBs, and correspondence. Many violations result in the bill being reversed entirely.
Even when the No Surprises Act doesn't apply, there are multiple strategies to overturn OON denials.
If there is no in-network provider within a reasonable distance who can provide the service, or the wait time for an in-network provider is unreasonably long, your insurer may be required to cover out-of-network care at in-network rates. This is called a "network adequacy" exception. Document the lack of available in-network providers.
If your provider left the network mid-treatment, many states require insurers to allow you to continue seeing that provider at in-network rates for a transitional period (typically 60-90 days, or through a course of treatment). Check your state's continuity of care laws.
If your situation falls under the No Surprises Act (emergency, non-consent OON at in-network facility, air ambulance), cite the specific provision in your appeal. Reference 42 USC 300gg-111 (emergency services) or 42 USC 300gg-131 (non-emergency at in-network facilities). The insurer must reprocess at in-network rates.
Many states have surprise billing laws that predate or go beyond the federal No Surprises Act. Check if your state has additional protections, such as hold-harmless provisions, payment standards for OON providers, or broader definitions of protected situations. Your state insurance department can help you understand what applies.
While appealing with the insurer, also file complaints with your state insurance department and CMS. Regulatory pressure often accelerates resolution. If the provider is balance billing you in a protected situation, report it — the provider can face penalties.
It depends on the situation. Under the No Surprises Act (effective January 2022), insurers cannot charge you more than in-network cost-sharing for emergency services at out-of-network facilities, non-emergency services by out-of-network providers at in-network facilities (like an out-of-network anesthesiologist during surgery at an in-network hospital), and air ambulance services. For planned, non-emergency care where you knowingly chose an out-of-network provider, the insurer can apply out-of-network benefits or deny the claim.
The No Surprises Act is a federal law effective January 1, 2022 that protects patients from surprise medical bills. It applies when you receive emergency care at an out-of-network facility, when you receive care from an out-of-network provider at an in-network facility without your consent, and for air ambulance services. Under this law, you only pay in-network cost-sharing amounts, and billing disputes are resolved between the provider and insurer — not billed to you.
Balance billing (or "surprise billing") occurs when an out-of-network provider bills you for the difference between their charge and what your insurance paid. The No Surprises Act prohibits balance billing in protected situations (emergencies, non-consent OON care at in-network facilities). Many states also have their own surprise billing laws that may provide additional protections. If you receive a balance bill in a protected situation, you can file a complaint with CMS or your state insurance department.
First, determine if your situation is protected under the No Surprises Act or your state's surprise billing laws. If so, file a complaint with CMS and your state insurance department. If the denial is for planned OON care, check if your plan has an exception process for situations where no in-network provider is available, the in-network wait is unreasonably long, or you need continuity of care with an OON provider. Submit an internal appeal with evidence, then proceed to external review if denied.
The No Surprises Act exists to protect you. ClaimBack generates appeal letters that cite the specific federal and state laws that apply to your out-of-network denial.
Start My Free Appeal →Takes 3 minutes · No login required
ClaimBack provides AI-assisted document drafting. We are not a law firm and do not provide legal advice.