Appeal guide · OON emergency

Out-of-network emergency denials

The federal No Surprises Act (NSA), effective 2022, prohibits balance billing and most out-of-network cost-sharing for emergency services regardless of facility or provider network status. Denials and balance bills that violate the NSA are appealable, and providers face federal independent dispute resolution (IDR) rather than billing the patient.

What gets denied

Emergency department visits at out-of-network hospitals
Out-of-network emergency physicians (ED docs, radiologists, pathologists, anesthesiologists)
Post-stabilization services before transfer
Air and ground ambulance (air covered by NSA; ground varies by state)
Out-of-network providers at in-network facilities

Common denial reasons

Plan paid only the 'allowed amount' and applied balance to the patient
Plan denied as out-of-network without honoring the emergency exception
Provider billed patient directly in violation of NSA
Plan claims service was non-emergent retrospectively

How we approach the appeal

Invoke the No Surprises Act directly. Federal rules require the plan to apply in-network cost-sharing to emergency services and prohibit balance billing for covered NSA services. File a complaint with the federal No Surprises Help Desk (CMS) if a provider continues to bill. Push the plan to issue a 'qualifying payment amount' and route disputes to federal IDR — not to the patient.

Filing window

Internal appeal: 180 days. NSA complaints to CMS can be filed at any time. State surprise-billing laws may add additional protections in some states.

Typical recovery

$1,000 – $250,000+

Documents we'll ask for

· Denial / EOB showing OON treatment
· Hospital and provider bills
· Emergency department records
· Insurance card and policy summary
· Any balance-bill notices received

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This page provides general information about appeal strategy. It is not legal advice. Outcomes depend on documentation, plan terms, and timing.