Not an emergency

What it means

Your plan says the visit was not an emergency. It may have denied the claim, paid only part, or treated the hospital as out of network. That reasoning can be wrong, because the federal test looks at your symptoms at the time, not at what the doctors found afterward.

For job-based plans (including Federal Employees Health Benefits plans), Marketplace plans and other individual plans, including grandfathered plans, the rules are:

• An emergency medical condition is judged by whether a prudent layperson, with 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. The test uses your symptoms, including severe pain, and includes mental health and substance use conditions.
• If the plan covers emergency department services at all, it must cover emergency services without prior authorization, in network or out.
• Your cost sharing cannot be more than in network, and it counts toward your in-network deductible and out-of-pocket maximum.
• A plan may not decide a visit was not an emergency solely on the basis of diagnosis codes.

These rules do not apply to short-term plans, health care sharing ministries or fixed indemnity plans. Medicare and Medicaid have their own rules.

Who has to act first

You do. Write down your symptoms now, while you remember them: what you felt, how fast it started, how bad it was, what you feared.

For a job-based plan or a non-grandfathered individual plan, you have at least 180 days after you receive the denial notice to file the first appeal, and your plan may allow more. For a payment appeal on a service already received, the plan has 60 days to decide, or 30 days at each level if it has two levels. Check the date on your notice, which controls.

Arguments that work

• The prudent layperson test. Quote it. Say what you felt and why a reasonable person would have gone. Do not argue from the final diagnosis.
• Diagnosis codes alone cannot decide it. Ask the plan to confirm that it did not rely only on the diagnosis codes. You can ask for the diagnosis and treatment codes and their meanings.
• No prior authorization. A denial because you did not call first conflicts with the emergency rule.
• Network status. For emergency services, an out-of-network hospital or doctor does not raise your share above in-network cost sharing.
• Surprise bills. A provider billing you more than in-network cost sharing for emergency care can be reported to the No Surprises Help Desk at 1-800-985-3059. Ground ambulance bills are not covered by these federal rules.

Evidence to gather

• Emergency room records: triage notes, physician notes, arrival time (the hospital).
• Your own written account of your symptoms (you).
• The explanation of benefits and denial notice with the stated reason (the plan).
• The diagnosis and treatment codes on the claim (the plan, on request).
• A short letter from the emergency physician if the records leave the symptoms unclear (the physician).

What to send

Send a written appeal with the emergency room records and your symptom statement. Use the emergency care appeal letter. Ask the plan to reprocess the claim under the prudent layperson standard and to give its decision in writing. If the plan upholds the denial and your plan is not grandfathered, you have at least four months after that final denial to request external review. If you are still in the hospital after a final internal denial that concerns emergency services, you may ask for expedited external review.