Surprise Medical Bill? Using the No Surprises Act Dispute Process
The No Surprises Act gives you two different tools, depending on whether insurance paid for your care. If you're insured, it caps what out-of-network providers can charge in many situations. If you're uninsured or paying cash, it gives you a written estimate and a way to challenge a bill that runs far over it.
AT A GLANCE
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"Surprise bill" covers many situations, and the law reaches only some. First figure out which side of the law you're on.
Your situation | What the law gives you | What you do if it's broken |
|---|---|---|
You have insurance and went to an emergency room | Out-of-network ER charges capped at in-network cost-sharing | Submit a complaint to the No Surprises Help Desk; appeal any insurer denial |
You have insurance and an out-of-network doctor treated you at an in-network hospital, outpatient department or surgery center | Protection from out-of-network charges unless you validly signed away your rights | Submit a complaint; appeal any insurer denial |
You have insurance and flew by air ambulance | Same out-of-network protections | Submit a complaint; appeal any insurer denial |
You're uninsured, or told the provider you weren't using insurance, and scheduled care in advance | A good faith estimate, and a dispute if a provider's bill is $400 or more over its estimate | Patient-provider dispute resolution ($25 fee, 120 days) |
You rode in a ground ambulance | Not covered by the federal protections; some states protect you | Call the provider, check state rules, ask for a reduction |
If you have insurance
What's protected
CMS says these protections apply if you have coverage through an employer (including a Federal Employees Health Benefits plan), the federal Health Insurance Marketplace, a state-based Marketplace, or other individual-market coverage.
Emergency care. If your plan covers emergency care, the hospital, the doctors treating you there and an air ambulance provider can't charge you more than your plan's in-network cost-sharing (copay, coinsurance or deductible). CMS counts hospital ERs, independent freestanding emergency departments, and hospital departments where you get post-stabilization care.
Planned care at an in-network facility. If your hospital, hospital outpatient department or ambulatory surgical center is in network but a doctor working there isn't, you're protected from out-of-network charges for care related to that visit. The protection doesn't reach an ordinary doctor's office that isn't a hospital outpatient department, or a facility that's out of network.
The form that can cancel your protection
An out-of-network provider may hand you a notice and consent form before scheduled care or after you've been stabilized in the ER. Signing it means you agree to out-of-network care and give up your surprise-billing protection. CMS's advice is direct: to save money and stay in network, don't sign the form.
CMS says the form must be given separately from your other paperwork, in the format you prefer, in any of the 15 most common languages in your state (with an interpreter if you speak another), and in advance. Some providers can never ask you to sign one:
emergency room providers, for emergency services;
anesthesiology, pathology, radiology and neonatology;
assistant surgeons, hospitalists and intensivists;
diagnostic services, including lab work;
any provider when there's no in-network provider at the facility who can do the service.
If one of them billed you out-of-network rates based on a signed form, file a complaint.
If you didn't sign a valid notice and consent form, an out-of-network doctor at an in-network hospital generally can't bill you more than in-network cost-sharing.
What's not protected
CMS lists these exceptions:
Ground ambulances. Federal protections generally don't apply, unless state law says otherwise.
Vision-only and dental-only plans, though protections may apply if those benefits are part of your health plan.
Short-term limited-duration plans and health care sharing ministries.
Fixed indemnity plans, such as hospital indemnity insurance.
Medicare, Medicaid, Indian Health Service, VA care and TRICARE already limit some out-of-network bills under their own rules.
CMS also notes that a bill for care before you've met your deductible isn't a No Surprises Act violation.
How to fight an insured surprise bill
Compare the bill with your Explanation of Benefits. CMS says the "your share" amount on the EOB should match what's on your bill.
Call the provider's billing office. Explain the care was emergency care or at an in-network facility, and ask for a rebill at in-network cost-sharing.
Submit a complaint to the No Surprises Help Desk online or at 1-800-985-3059 if you got an out-of-network bill for ER care or care at an in-network facility, already paid more than in-network rates, or the provider didn't follow notice-and-consent rules.
Appeal an insurer denial through your plan's internal appeal process, using the steps in your plan documents and denial notice.
Ask for external review if the internal appeal fails. Federal rules (45 CFR 147.136) require external review to cover denials that turn on whether a plan complied with surprise-billing protections. HealthCare.gov says you must file within 4 months of the final denial, and the reviewer's decision binds the insurer.
Continuing care when a doctor leaves your network
If your provider leaves your plan's network, CMS says "continuing care patients" may keep getting care from them at in-network rates for up to 90 days. That includes people being treated for a serious and complex illness, in inpatient or institutional care, scheduled for non-elective surgery, pregnant and in treatment, or terminally ill.
If you're uninsured or paying cash
The good faith estimate
If you don't have insurance, or you tell the provider you aren't using it, you're usually owed a written good faith estimate. It's a list of expected charges, including facility fees, not a bill.
CMS sets out the timing:
When you schedule | When the estimate is due |
|---|---|
0 to 2 business days ahead | No estimate required |
3 to 9 business days ahead | Within 1 business day of scheduling |
10 or more business days ahead | Within 3 business days of scheduling |
You ask before scheduling | Within 3 business days of asking |
There's no estimate during emergency care. And each estimate covers a single provider or facility, so for a surgery CMS suggests asking for two: one from the surgeon and one from the hospital. Separately scheduled visits, such as pre-surgery appointments or later physical therapy, may not be included.
When you can dispute
CMS's patient-provider dispute resolution process is open only if all of these are true:
You didn't have or didn't use insurance, and told the provider in advance.
You got care on or after January 1, 2022.
You have a good faith estimate from that provider or facility.
Your first bill is dated within the last 120 calendar days.
One provider or facility billed at least $400 more than its own estimate.
The $400 test applies to each provider separately. In CMS's examples, providers $375 and $325 over can't be disputed, though together they're $700 over. A new item that wasn't on the estimate counts toward the difference.
How the dispute works
Gather your documents: the good faith estimate, the bill, and the provider's contact information. Don't mail originals.
Start the dispute online on CMS's site (you'll verify with an email and one-time PIN) or by mail or fax with CMS's form.
Pay the $25 non-refundable fee by credit card, PayPal or Venmo online, or by money order or cashier's check by mail. The dispute doesn't start until it's paid. If you win, the $25 comes off what you owe the provider.
An independent reviewer decides. If the extra care couldn't have been anticipated, the bill stays. If the provider should have told you about the costs, or the added services weren't medically necessary, the provider must reduce the bill. CMS says your costs won't go up no matter the outcome.
While the dispute is open, CMS says the provider can't send the bill to collections or threaten to, can't collect late fees on it, and can't retaliate. If it's already in collections, collection must stop. If you settle with the provider before a decision, the provider must cut the bill by at least $12.50, half the fee.
If you never got an estimate
You can't use the dispute process without one. Ask the provider for a copy if you lost it. If you didn't get one and should have, submit a complaint. If you scheduled care and haven't received one yet, ask for it in writing; CMS says you don't need to use the term "good faith."
Ground ambulance bills
Ground ambulances sit outside the federal law. CMS's ground ambulance action plan lists 10 states with ground ambulance billing protections as of November 15, 2021: Colorado, Delaware, Florida, Illinois, Maine, Maryland, New York, Ohio, Vermont and West Virginia. That list is from 2021, so check with your state insurance department or Consumer Assistance Program for current rules. In any state, CMS suggests asking the provider for a lower bill or a payment plan.
Before you call
☐ The bill and the date you received it (the 120-day clock starts with the first bill)
☐ Your Explanation of Benefits, if you used insurance
☐ Any good faith estimate, for each provider
☐ Any notice and consent form you signed, with its date
☐ Your plan's denial letter and appeal deadline, if the insurer denied the claim
☐ A payment method for the $25 dispute fee, if you're uninsured
WHAT TO DO THIS WEEK
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Related help
If the bill doesn't involve out-of-network care but still looks off, use our guide to getting an itemized hospital bill and disputing errors. If your insurer says a claim was paid but the provider keeps billing, see what to do when the EOB says paid. If the amount is correct but unaffordable, read about hospital charity care.
Official sources
Last checked: October 23, 2026 (CMS No Surprises Act consumer pages, dispute page and examples PDF, ground ambulance action plan, HealthCare.gov external review page and 45 CFR 147.136).
Some states have their own surprise-billing laws that add to the federal rules. Ask your state insurance department or Consumer Assistance Program what applies to your plan.
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