Out-of-Network Appeal Help
Federal law prohibits surprise medical billing for emergency care and many non-emergency services. If your insurer denied your out-of-network claim, you likely have stronger protections than you realize.
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The No Surprises Act (Public Law 117-169), effective January 1, 2022, is the most significant patient financial protection law in a generation. It specifically addresses the problem of patients receiving massive bills from out-of-network providers they did not choose or could not avoid.
All emergency care must be covered at in-network rates, regardless of which facility or provider you see. No balance billing allowed.
Out-of-network providers at in-network facilities (anesthesiologists, radiologists, etc.) cannot balance bill you if you did not choose them.
Out-of-network air ambulance services are covered at in-network rates. You pay only your in-network cost-sharing amount.
Emergency care coverage is based on your symptoms at the time you sought treatment, not the final diagnosis. If a reasonable person would have believed they needed emergency care, the insurer must cover the visit. Insurers cannot retroactively deny emergency claims because the final diagnosis was not life-threatening.
Sources: Peterson-KFF Health System Tracker, CMS No Surprises Act data, state insurance department reports
Upload the denial or surprise bill. Our AI identifies whether the No Surprises Act, state balance billing laws, or network adequacy requirements apply to your specific situation.
AppealArmor determines whether your situation is covered by the No Surprises Act, the prudent layperson standard, state network adequacy laws, or balance billing prohibitions. We cite the specific statutory sections and regulations that apply.
Your packet includes an appeal letter citing the No Surprises Act and applicable state law, a complaint to report illegal balance billing if applicable, and instructions for requesting Independent Dispute Resolution (IDR) if needed.
If you chose to go out-of-network, you may still have strong grounds for appeal. Many states require insurers to cover out-of-network care at in-network rates when their network is inadequate. This applies when:
If you received emergency care, or if you were treated by an out-of-network provider at an in-network facility without choosing that provider, the No Surprises Act protects you. You can only be charged your in-network cost-sharing amount (copay, coinsurance, deductible). The provider cannot send you a balance bill for the remainder.
Emergency coverage is determined by your symptoms, not the final diagnosis. If a reasonable person with average medical knowledge would have believed they needed emergency treatment based on their symptoms, the visit must be covered. Chest pain that turns out to be heartburn is still a covered emergency visit because a prudent layperson would seek immediate care for chest pain.
No. Under the No Surprises Act, balance billing for emergency services is prohibited. If you receive a balance bill for emergency care, report it to CMS at 1-800-985-3059 and to your state insurance department. The provider and insurer must resolve payment disputes through the Independent Dispute Resolution process -- not by billing you.
You can still appeal. If the insurer's network lacked an available provider for your condition, state network adequacy laws may require in-network coverage rates. If you signed a consent form waiving No Surprises Act protections, that waiver may be invalid if it was not properly presented or if it was signed under coercion. AppealArmor identifies the strongest legal arguments for your specific situation.
AI-powered, evidence-based, ready to mail or email. Most denials are never appealed — the ones that are often succeed.
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