Does the No Surprises Act cover every out-of-network claim?

No. Federal protections generally cover most emergency services, certain non-emergency services from out-of-network providers during a visit to an in-network hospital, hospital outpatient department, or ambulatory surgical center, and out-of-network air ambulance services. They generally do not cover planned non-emergency care at an out-of-network facility, ground ambulance services, or services the plan does not cover.

What if the plan's directory said the provider was in network?

If inaccurate network information from the plan caused you to receive covered care from an out-of-network provider or facility, federal provider-directory protections may limit you to in-network cost sharing. Preserve screenshots, call reference numbers, dates, and any written confirmation.

Can an out-of-network denial be appealed?

Yes. HealthCare.gov identifies care from a provider or facility outside the plan's approved network as a denial that can be challenged through an internal appeal. Follow the deadline and filing instructions in your denial notice.

Out-of-network denial: check the rule before paying the bill

UPDATED JULY 2026 · U.S. COMMERCIAL PLANS · NOT LEGAL OR MEDICAL ADVICE

“Out of network” can describe two different disputes: what your health plan paid and what the provider billed you. Start by separating them. Some situations have federal surprise-billing protections; others depend on your plan's out-of-network benefits, a directory error, or a plan- and state-specific network exception.

Federal protections commonly apply when

You received most emergency services, even from an out-of-network provider or emergency facility.
An out-of-network clinician treated you during a visit to an in-network hospital, hospital outpatient department, or ambulatory surgical center.
You used an out-of-network air ambulance for a covered service.
The plan gave you inaccurate provider-directory information and you relied on it for covered care.

First: compare the EOB with the provider's bill

Your Explanation of Benefits (EOB) is the plan's accounting; the medical bill is the provider's demand for payment. Check whether the claim was denied completely, processed at out-of-network cost sharing, or paid correctly while the provider separately balance billed you. Write down every mismatch.

An internal appeal challenges the plan's processing. A billing complaint challenges possible surprise-billing violations. You may need to do both, and a complaint does not pause the appeal deadline in your denial notice.

Does the No Surprises Act fit your situation?

For most private group and individual coverage, the federal No Surprises Act generally limits covered emergency care, specified non-emergency care at certain in-network facilities, and covered air-ambulance care to the applicable in-network cost sharing. Those amounts must count toward your in-network deductible and out-of-pocket maximum. See the CMS consumer guide to using insurance.

The federal rules do not cover every high or unexpected bill. They generally do not protect planned non-emergency care from an out-of-network provider at an out-of-network facility, ground ambulance services, or an item or service your plan would not cover even in network. Signing a valid notice-and-consent form can also waive some protections for certain non-emergency services. State law may add protections.

Build the paper trail

EOB and itemized bill: mark the denial code, allowed amount, plan payment, and the amount the provider says you owe.
Network proof: save dated directory screenshots, portal messages, and call reference numbers showing what the plan told you.
Facility and provider status: an in-network facility can still use an out-of-network clinician. Document both.
Emergency record: include the symptoms and circumstances documented when you sought care, plus the claim and facility records.
Consent documents: request any notice-and-consent form the provider says you signed.
Plan terms: obtain the Evidence of Coverage or Summary Plan Description and the plan's appeal procedure.

Choose the argument that matches the facts

Protected emergency or facility-based care

Ask the plan to reprocess the claim under the No Surprises Act and apply only the in-network cost-sharing amount. If the plan upholds its decision, No Surprises Act compliance determinations can be eligible for external review.

The directory or plan representative was wrong

If the plan's directory, website, or response to your network-status question said the provider was in network, attach that proof. Federal provider-directory protections may require in-network cost sharing when inaccurate plan information caused the out-of-network care.

No suitable in-network provider was available

Ask whether your plan offers a network-gap exception or single-case agreement. Document the in-network providers you contacted, their specialties, distance, wait times, and why they could not provide the covered service. Whether an exception is available depends on your plan and applicable state rules; do not describe it as guaranteed.

The plan includes out-of-network benefits

Quote the exact plan language for deductibles, coinsurance, allowed amounts, referrals, and prior authorization. If the plan used the wrong tier, code, or benefit rule, identify the discrepancy and ask for corrected processing.

The appeal letter

Free template — out-of-network claim appeal

[Your name] · Member ID: [ID] Claim / Reference #: [number] · Date of service: [date] [Plan / insurer] — Appeals Department [Address or portal from denial notice] RE: Appeal of out-of-network denial or cost sharing — [provider, facility, service] To the Appeals Department: I appeal the decision dated [date] concerning [service]. The EOB states: "[quote the denial reason or processing explanation]." I request that the claim be reprocessed for the following documented reason(s): 1. [IF FEDERALLY PROTECTED] NO SURPRISES ACT PROTECTION. The service was [emergency care / care from an out-of-network provider during a visit to an in-network hospital, hospital outpatient department, or ambulatory surgical center / covered air-ambulance care]. Please apply the in-network cost-sharing requirements and credit the amount to my in-network deductible and out-of-pocket maximum. 2. [IF DIRECTORY ERROR] RELIANCE ON PLAN INFORMATION. On [date], your [online directory / representative / written response] stated that [provider or facility] was in network. A screenshot or call record is enclosed. I relied on that information when receiving covered care and request in-network cost sharing. 3. [IF NETWORK GAP] NO SUITABLE IN-NETWORK OPTION. I contacted [providers, dates, results]. They could not provide the required service because [specialty, availability, distance, or clinical reason]. Please evaluate this request under any network-gap or single-case exception available under my plan. Enclosed: EOB; itemized bill; denial notice; directory screenshots or call log; relevant medical or emergency records; consent documents, if any; plan-language excerpt. Please send a written determination that identifies the plan provisions and rules applied. If you uphold a decision involving No Surprises Act compliance, please include the instructions and deadline for independent external review. Sincerely, [Signature] · [Name] · [Phone]

If the provider's bill may violate federal protections

Contact the provider's billing office in writing, identify the disputed amount, and ask it to place the account on hold while the plan appeal and complaint are reviewed. You can also use the CMS No Surprises complaint portal or call the No Surprises Help Desk at 1-800-985-3059. Do not use the federal provider-plan Independent Dispute Resolution process yourself; that payment process is for plans and providers.

Turn the records into a clear packet

Upload the denial and organize the two disputes.

GetMyYes drafts an appeal from the actual EOB or denial, builds an evidence checklist, and gives you a separate call script for the plan and provider. Review every fact before filing.

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Frequently asked questions

Does federal law cover a ground ambulance bill?

Generally not under the No Surprises Act, although state law may provide separate protection. Check your plan documents and state insurance regulator's guidance.

What if I signed a notice-and-consent form?

A valid form can waive some protections for certain scheduled non-emergency or post-stabilization services. It cannot be used in every setting or for every service. Request a copy and compare it with the CMS rules before deciding how to frame the appeal or complaint.

Can I rely on a provider saying it accepts my insurance?

“Accepts insurance” is not the same as “in network.” Verify with the plan and keep the response. If the plan itself gave inaccurate directory or network-status information and you relied on it, attach that evidence to your appeal.