Key points
- Emergency care is judged by your symptoms when you arrived, using a "prudent layperson" test. The final diagnosis does not decide it.
- If your plan covers emergency department services at all, it cannot require prior approval for emergency care. It must treat an out-of-network emergency provider at in-network cost sharing.
- Appeal in writing, attach your emergency room records, and ask for external review if the plan upholds the denial.
If your plan denied or cut an emergency room claim, the plan is probably saying one of three things: it was not an emergency, you should have called first, or the hospital was out of network. For the plans covered below, none of those is a safe reason to refuse by itself.
What this means
The federal rules on emergency care come from the No Surprises Act. They apply to job-based plans (including the Federal Employees Health Benefits program), Marketplace plans and other individual plans, including grandfathered plans. They do not apply to short-term plans, health care sharing ministries or fixed indemnity plans. Medicare, Medicaid and military coverage have their own rules, which this guide does not cover. See your coverage type page for those.
For the plans covered, the rules are:
- A prudent layperson standard. An emergency medical condition is judged by whether a prudent layperson, who has an average knowledge of health and medicine, could reasonably expect that going without immediate care would seriously jeopardize health, seriously impair bodily functions, or cause serious dysfunction of an organ. It is based on your symptoms, including severe pain. It includes mental health and substance use conditions.
- No prior authorization. If the plan covers emergency department services at all, it must cover emergency services without prior authorization, whether the provider or facility is in network or not.
- In-network cost sharing. Your cost sharing for emergency services cannot be greater than it would be in network, and it counts toward your in-network deductible and out-of-pocket maximum.
- The diagnosis is not the test. A plan may not decide that a visit was not an emergency solely on the basis of diagnosis codes.
A denial or higher cost sharing that depends on whether these protections apply is a denial you can take to external review, including under a grandfathered plan.
What to do
- Get the denial notice and the explanation of benefits. Find the stated reason and the codes the plan used. If you do not see the diagnosis and treatment codes, ask the plan for them, with their meanings. A non-grandfathered plan must provide them as soon as practicable on request. (You.)
- Write down your symptoms. Write what you felt when you decided to go: where, how severe, how fast it started, what you feared. Do this while you remember it. (You.)
- Request the emergency room records. The triage notes and the physician’s notes show the symptoms recorded on arrival. Use the medical records request letter. (You.)
- Ask your doctor or the emergency physician for a short letter if the records do not make the symptoms clear. (Your doctor.)
- File the appeal. Use the emergency care appeal letter. Quote the prudent layperson standard and say your symptoms. Employer and non-grandfathered individual plans must allow at least 180 days after you receive the denial to appeal. Check the date on your notice, which controls. (You.)
- Ask for external review if the plan upholds the denial. You have at least four months after the final denial. If you are still in the hospital after a final internal denial that concerns emergency services, you may ask for expedited external review. (You.)
- Complain about a surprise bill. If a provider billed more than in-network cost sharing, the surprise bills guide gives the complaint route. (You.)
What the plan may say, and what to say back
“The final diagnosis was not an emergency.” The test is your symptoms at the time, judged as a prudent layperson would. A plan may not decide a visit was not an emergency solely on diagnosis codes. Ask the plan to reprocess using the symptom standard.
“You should have called us first.” A plan that covers emergency department services must cover emergency services without prior authorization.
“The hospital is out of network.” For emergency services, network status does not change your cost sharing. Ask the plan to reprocess at in-network cost sharing and count it toward your deductible and out-of-pocket maximum.
“You should have gone to urgent care.” The standard is what a prudent layperson would reasonably expect. Describe what you feared and why.
The rule
An emergency medical condition is judged by the prudent layperson standard, based on symptoms including severe pain, and includes mental health and substance use conditions. 45 Code of Federal Regulations (CFR) 149.110
Watch for
- Doctor bills separate from the hospital. The emergency physician, radiologist or other clinician may send a separate bill. Emergency medicine and diagnostic services such as radiology and laboratory services can never be waived under the surprise billing rules. See the surprise bills guide.
- Ground ambulance. The No Surprises Act does not protect against ground ambulance bills. See the ambulance bills guide.
- Follow-up care. The emergency rules cover emergency services. We could not confirm how the rules treat care you get after you are stabilized, or later visits for the same problem. Ask the plan. Ask the plan in writing which rules it applied, and read 45 CFR 149.110.
- Do not delay emergency care to check coverage. For the plans covered here, the plan cannot require approval first.
What next
- Surprise bills and the No Surprises Act: who is protected and how to complain.
- Ambulance bills: why ground ambulance is different.
- File an internal appeal: the steps for the first appeal.
- Out-of-network and emergency care topic page: all related guides and letters.