Surprise bill response

Was it emergency careIf your plan covers emergency services at all, it must cover them without prior authorization, in or out of network, with cost sharing no higher than in network.Did an out-of-network clinician treat you at an in-network hospital or surgery centerThat clinician may not bill you more than in-network cost sharing unless you signed a valid notice-and-consent waiver.Did you sign a consent form before the serviceA waiver can never be used for emergency medicine, anesthesiology, pathology, radiology, neonatology, assistant surgeons, hospitalists, intensivists, diagnostic services, or when no in-network provider was available.Was it an air ambulanceAn out-of-network air ambulance provider may not bill you more than in-network cost sharing, but ground ambulance services are not covered by the Act.Is your plan one the Act coversThe Act covers employer plans, federal employee plans, marketplace plans and other individual plans, but not short-term plans, health care sharing ministries or fixed indemnity plans.

Your Explanation of Benefits and the provider's bill, side by sideThe difference between what you were charged and what in-network cost sharing would have been is the amount in question.An itemized billYou have a right under the Health Insurance Portability and Accountability Act (HIPAA) to your provider's billing records, and the provider must act on your request within 30 days.Your plan's provider directory entry, if you relied on itIf the directory wrongly listed the provider as in network, the plan may not charge you more than in-network cost sharing and must count it toward your in-network deductible and out-of-pocket maximum.Any papers you signed at check-inA valid waiver needs written notice at least 72 hours before a service scheduled 72 or more hours ahead, a good faith estimate of charges, and a statement that consent is optional.

Ask the provider in writing to bill only in-network cost sharing and to hold the billThe provider is the one who may not bill you more, so say which protection applies.Ask your plan to reprocess the claim at in-network cost sharingYour cost sharing should count toward your in-network deductible and out-of-pocket maximum.Write down when the plan must answerFor protected services the plan must pay or send a notice of denial to the provider within 30 calendar days after it has the information it needs.Remember the payment dispute is between the plan and the providerYou owe only in-network cost sharing, and you are not a party to the federal dispute process between them.

Appeal the plan's decisionA denial or higher cost sharing that turns on whether the Act applies is eligible for external review, including for grandfathered plans.Complain to the No Surprises Help DeskCall 1-800-985-3059 or use the online complaint form, and the federal government must acknowledge the complaint within 60 business days.Do not let the plan call it non-emergency because of a diagnosis code aloneA plan may not decide a visit was not an emergency solely on the basis of diagnosis codes, and the test is what a prudent layperson would reasonably expect from your symptoms.

Ask for a good faith estimate before scheduled careYou must get one within 1 business day of scheduling if the service is at least 3 business days away, within 3 business days if it is at least 10 business days away, and within 3 business days of a request.Compare the bill with the estimateYou can dispute the bill if the provider's total charges are at least $400 more than its good faith estimate.Start the dispute within 120 calendar days of the initial billThe administrative fee is $25 as of 11 November 2026, and the provider must not send the bill to collections or threaten to while the dispute is pending.

Surprise bill response

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