What Is the No Surprises Act
The No Surprises Act is a federal law that took effect January 1, 2022, requiring health plans and providers to limit patient cost-sharing for out-of-network emergency services and certain non-emergency services to in-network rates. Specifically, you cannot be billed more than the in-network copay, coinsurance, or deductible, even if the provider is out-of-network.
The law applies to emergency department visits, ambulance services, and non-emergency services performed by out-of-network providers at in-network facilities (like a surgeon who doesn't participate in your plan operating at your plan's hospital). It also covers ancillary services like anesthesia, radiology, and pathology at in-network facilities.
How It Protects You in Claims and Appeals
When you receive a surprise bill, the No Surprises Act creates specific remedies you can pursue. First, examine your Explanation of Benefits (EOB). If an out-of-network provider billed you more than your in-network cost-sharing amount, that bill violates the law. The provider should have been paid according to the qualifying payment amount, which is the lesser of the provider's billed charge, the qualifying payment amount determined by your plan, or the average contracted rate for that service in your area.
You have two appeal paths for No Surprises Act violations:
- Internal appeal: File with your health plan within 180 days of receiving the EOB. Your plan must acknowledge receipt within 5 business days and decide within 30 days for standard appeals or 72 hours for expedited reviews. The plan is required to overturn the denial if the service qualifies under the law.
- External appeal: If your plan denies your internal appeal, you can request an independent external review from your state's insurance commissioner within 60 days. The external reviewer has 72 hours (expedited) or 30 days (standard) to decide.
Keep documentation showing you received prior authorization or that emergency care was medically necessary. These strengthen your internal appeal by demonstrating the service qualified for protection.
State Insurance Regulations and Variations
While the No Surprises Act is federal, your state insurance commissioner enforces it within your state. Some states have enacted additional protections beyond federal minimums. For example, Texas and Florida have state-level surprise billing laws with their own timelines and remedies. California's Department of Insurance maintains specific complaint procedures for No Surprises Act violations that may differ from other states' processes.
Check your state insurance department website for complaint filing procedures. Most states allow you to file complaints online, and doing so creates an official record that your plan must address.
Medical Necessity and Denials Under the Act
Insurance plans sometimes deny out-of-network claims by claiming the service wasn't medically necessary. However, the No Surprises Act limits this defense. If a plan denies an emergency service as not medically necessary, they must prove the patient knew it was non-emergency before receiving care. For non-emergency services at in-network facilities, the plan's denial of medical necessity must follow standard appeal procedures and cannot override your cost-sharing protections.
When appealing a denied claim involving an out-of-network provider, cite the specific No Surprises Act regulation (42 CFR 49.2) in your written appeal. State that regardless of medical necessity determinations, your cost-sharing is limited to in-network levels under federal law.
Common Questions
- Can a provider still bill me under the No Surprises Act? No. The law prohibits balance billing entirely for covered services. If you receive a bill from an out-of-network provider for an emergency or covered non-emergency service, contact your plan's compliance department immediately with a copy of your EOB.
- What if my plan never provided prior authorization? The No Surprises Act doesn't require prior authorization for emergency services. If your plan is denying coverage based on missing prior auth for emergency care, file an internal appeal stating this requirement conflicts with federal law.
- How long can I pursue this claim? You have 180 days from the EOB date to file an internal appeal. After denial, you have 60 days to request external review. Beyond that, you may pursue state insurance complaints or small claims court depending on the amount owed.