How to appeal an out-of-network denial

The No Surprises Act took effect on January 1, 2022. It protects people with most private insurance from unexpected out-of-network bills in three situations:

• Emergency care at a hospital emergency room or a freestanding emergency department.
• Non-emergency care from an out-of-network provider during a visit to an in-network hospital, hospital outpatient department or ambulatory surgical center.
• Air ambulance services.

The protections apply to coverage through an employer, including the Federal Employees Health Benefits program, the federal or a state Marketplace, and other individual coverage.

For emergencies, the plan must cover the care without any prior authorization, even out of network, and cannot charge you more cost-sharing than it would in network. For covered out-of-network care at an in-network facility, your cost-sharing cannot be higher than in network, unless you validly signed a notice-and-consent form. Some providers, including anesthesiologists, radiologists, pathologists, neonatologists, hospitalists and assistant surgeons, are not allowed to ask you to sign that form.

If the plan processed one of these claims as out of network, say so in the appeal. Denials that involve whether a plan followed these rules are eligible for external review.

As of November 2026, ground ambulance services generally are not covered by the No Surprises Act's billing protections, unless a state law has different rules. If you get an out-of-network ground ambulance bill, CMS notes that the ambulance provider may be able to lower the bill or set up a payment plan, and some states have their own protections.

The protections also do not apply in settings such as a doctor's office that is not a hospital outpatient department, or if you choose an out-of-network facility. Short-term limited duration plans and health care sharing ministries are not subject to them. CMS notes that Medicare, Medicaid, TRICARE and VA health care already protect you from some unexpected out-of-network bills.

If you went out of network because no in-network provider could do the work, ask the plan whether it has a network exception. It may be called a gap exception or an in-network exception, and the rules come from your plan document and state law.

Federal regulators use this situation as an example in the external review rules. In that example, a plan covers out-of-network care only when a service cannot effectively be provided in network, and a patient who says that is true of a specialized procedure is denied. The regulators concluded that the denial involves medical judgment and is eligible for external review, and that the denial notice should describe the plan's standards and how the in-network options meet them.

To support an exception request or an appeal, gather:

• Screenshots or printouts of the plan's provider directory for your specialty and area, with dates.
• Notes on calls to in-network providers: names, dates and what you were told, such as no new patients, no appointment for months, or no one who does the procedure.
• A letter from your doctor explaining why the in-network options are not appropriate for your condition.
• Any referral or approval you received before the care.

If you have not had the care yet, ask for the exception before treatment and get the answer in writing.

If you are in the middle of treatment when your doctor or hospital leaves your plan's network, you may be able to keep seeing them at in-network rates for a while. Under the No Surprises Act, continuing care patients can get care from their provider at in-network rates for up to 90 days. That includes people being treated for a serious and complex illness, people in institutional or inpatient care, people scheduled for non-elective surgery, pregnant people in treatment, and people who are terminally ill.

The law, 42 U.S.C. 300gg-113, requires the plan to notify each continuing care patient and let them choose to continue care. It does not apply when the contract ended for failure to meet quality standards or for fraud. If you never got a notice, ask the plan in writing for continuity-of-care coverage and note the date you learned the provider had left.

In Medicare Advantage, if a plan provider refers you to a provider outside the network without getting approval in advance, Medicare calls it plan directed care, and in most cases you will not pay more than the plan's usual cost sharing. Raise this in the appeal if your in-network doctor sent you.

Medicare Advantage plans must also cover emergency services regardless of whether there is prior authorization, judged by the prudent layperson standard, regardless of final diagnosis. See Medicare Advantage appeals for deadlines.

Appeal deadlines depend on your plan type. See the pages for employer plans, Marketplace plans, Medicare Advantage, Original Medicare and Medicaid. Keep copies of the Explanation of Benefits, any bills, and every letter from the plan.

For problems with No Surprises Act protections, CMS runs a help desk at 1-800-985-3059. For individual and fully insured plans, your state insurance department also takes complaints.