Federal law protects you from surprise ER bills — insurers must comply.

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The No Surprises Act protects you. Make your insurer follow the law.

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Understanding Your Emergency Room Services Denial

Since 2022, the No Surprises Act helps protect patients from surprise bills when they receive emergency care at out-of-network facilities. Yet insurers continue to improperly deny or underpay these claims. You normally cannot be balance-billed more than your in-network cost-sharing, and your insurer must pay the emergency facility appropriately. If your claim was denied or you received a surprise bill, you have strong appeal rights.

Common Reasons for Denial

  • ! Out-of-network provider
  • ! Emergency not verified
  • ! Post-stabilization care not covered
  • ! Claim filed incorrectly
  • ! Balance billing by provider

How We Help

We help you document the emergency nature of your visit, cite the No Surprises Act protections, and explain why your insurer must cover the claim at in-network cost-sharing levels.

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Some Types of Evidence We Can Use For Supporting Your Appeal

✓ The No Surprises Act requires insurers to cover emergency services at out-of-network facilities without requiring prior authorization.

✓ Patients cannot be charged more than in-network cost-sharing for emergency services regardless of network status.

✓ Emergency medical conditions are defined as those requiring immediate medical attention to prevent serious health consequences.

✓ The prudent layperson standard requires that insurance coverage for emergency care be based on the patient's presenting symptoms, not the final diagnosis (American College of Emergency Physicians).

✓ An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson could reasonably expect the absence of immediate medical attention to place their health in serious jeopardy.

✓ Patients are not expected to diagnose themselves; roughly 90% of urgent and non-urgent symptoms overlap, so an emergency visit cannot be judged by its final diagnosis.

While You're Fighting Your Denial

Talk to your provider about these options that might help bridge the gap:

→ File a complaint with your state insurance department if you receive a surprise balance bill.

→ Request the Independent Dispute Resolution process if your insurer and provider can't agree on payment.

→ Contact the CMS No Surprises Help Desk at 1-800-985-3059 for assistance.

Patient Advocacy & Support Organizations

These organizations provide education, support, and advocacy for patients:

Prudent Layperson Standard — American College of Emergency Physicians ↗

ACEP patient resource: insurers must cover emergency care based on your symptoms, not your final diagnosis.

EMTALA and Prudent Layperson Standard FAQ — ACEP ↗

ACEP FAQ on how EMTALA and the prudent layperson standard require covering emergency services based on presenting symptoms.

Frequently Asked Questions

Federal law since January 2022 that protects patients from surprise bills when receiving emergency care, even at out-of-network facilities. Your insurer must cover the claim and you only owe in-network cost-sharing.

Normally no. Under the No Surprises Act, out-of-network emergency providers cannot balance bill you for more than your in-network deductible and coinsurance. Report violations to your state insurance department. Unfortunately there are exceptions (including ground ambulances).

Some post-stabilization care at out-of-network facilities can be protected until you can safely be transferred. Your appeal should document that you were not stable enough to transfer.

Federal law (and most state laws) require insurers to cover emergency care based on your symptoms at the time, not the final diagnosis. If a reasonable person with average medical knowledge would have believed an emergency existed, the visit must be covered — even if testing later showed it was not serious. This protection was first required nationally by the Balanced Budget Act of 1997 and reinforced by the Affordable Care Act.

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Disclaimer: Fight Health Insurance is not affiliated with, endorsed by, or partnered with any pharmaceutical manufacturer, healthcare provider, medical device company, or patient assistance program. All information provided is for educational and informational purposes only and does not constitute medical or legal advice. Please consult with your healthcare provider regarding treatment options and with your insurance company regarding coverage decisions.