Out-of-network and emergency care

Guides

• Ambulance bills

  Air ambulance bills are covered by the federal No Surprises Act. Ground ambulance bills are not. Here is what to do about an ambulance bill or a denied ambulance claim.

• Emergency room claim denied

  What to do when your plan denies or reduces an emergency room claim. Learn the prudent layperson standard and why a plan cannot require prior approval for emergency care.

• Out-of-network denials and network gap exceptions

  What to do when your plan denies or underpays care because the provider is out of network. Learn about network gap exceptions, continuity of care and the cases federal law protects.

• Out-of-network underpayment

  Your plan paid an out-of-network claim but far less than the provider charged. Learn how plans set the allowed amount and how to use price benchmarks in a dispute.

• Surprise bills and the No Surprises Act

  Who the federal No Surprises Act protects, which out-of-network bills it bars, which it does not, and how to complain to the No Surprises Help Desk.

Tools

• Tool

  Network exception builder

  Build a request to cover out-of-network care at in-network cost when the network cannot provide what you need.

• Tool

  Surprise bill checker

  See whether the federal No Surprises Act may protect you from an out-of-network bill, with three plain steps, a phone script and two letters.

Letters and scripts

• Letter or script

  Appeal: emergency care denied

  Asks your plan to cover an emergency visit using the prudent layperson standard, judged on your symptoms at the time rather than the final diagnosis.

• Letter or script

  Appeal: out of network because no in-network option exists

  Asks your plan to cover out-of-network care at the in-network level because no in-network provider could give the care in time, or at all.

• Letter or script

  Appeal: out-of-network allowed amount too low

  Asks your plan to explain how it set the allowed amount for out-of-network care, to reprocess the claim if the method was wrong, and to pay the difference.

• Letter or script

  Ask your plan to reprocess a claim under the No Surprises Act

  Ask your plan to reprocess a claim with the No Surprises Act protections, so you pay only in-network cost sharing that counts toward your in-network limits, and to treat the letter as an appeal if the claim stays denied.

• Letter or script

  No Surprises Act complaint

  Tell the federal government that you were billed more than the No Surprises Act allows, using the No Surprises Help Desk or the online complaint form.

• Letter or script

  Out-of-network necessity letter (for your clinician)

  A letter in your clinician's voice explaining why in-network care cannot meet the patient's needs, so the plan should cover an out-of-network provider. Every clinical and network statement is a blank for the clinician to complete.

• Letter or script

  Phone script: first call to the billing office about a surprise bill

  What to say on your first call to a provider's billing office about a bill that may be a surprise bill: what to ask for, what to write down, how to ask for a hold in writing, and what to say if they mention collections.

• Letter or script

  Tell the provider the No Surprises Act may apply to your bill

  Write to the provider's billing office to say the federal No Surprises Act may apply, ask them to bill only your in-network share, hold the account while your plan reprocesses the claim, and confirm in writing.

Checklists

• Checklist

  Surprise bill response

  How to check whether the No Surprises Act protects you from an unexpected out-of-network bill, who to ask to fix it, and where to complain.

Denial reasons

• Denial reason

  Allowed amount too low

  Your plan paid an out-of-network provider only part of the bill and says the rest is above its allowed amount. Check how the plan set that amount, whether surprise-billing protections apply, and what typical prices are in your area.

• Denial reason

  Not an emergency

  Your plan says your emergency room visit was not a true emergency, so it denied the claim or paid it at a lower rate. The test is what your symptoms looked like to an ordinary person, not the final diagnosis.

• Denial reason

  Out of network

  The plan says your provider or facility is not in its network. Federal law protects you in emergencies and in several hospital situations, so check which situation you are in before you pay.

Programs and services

Run by other organizations.

• Program or service

  FAIR Health Consumer cost estimates

  A nonprofit's tools for estimating what providers charge and what insurers pay in your area, plus insurance basics. Useful evidence in an out-of-network payment dispute. It does not file appeals or negotiate for you.

  From FAIR Health

• Program or service

  No Surprises Help Desk: surprise bill questions and complaints

  The federal help desk for questions or complaints that a plan, provider or facility broke the surprise billing rules. It reviews the complaint and may refer it to another federal or state enforcer.

  From Centers for Medicare & Medicaid Services