No Surprises Act: What to Do About a Surprise Medical Bill
By Dalton Goodyear · Fact-checked October 31, 2026 · 7 min read
The short answer
The No Surprises Act protects most people with private insurance from surprise out-of-network bills for emergency care, many non-emergency services at in-network facilities, and air ambulance rides. You generally owe only your in-network cost-sharing. If you are uninsured or self-pay and your bill is at least $400 over your Good Faith Estimate, you can dispute it within 120 days.
- Protected: emergency care, many services from out-of-network doctors at in-network hospitals, and air ambulance. Ground ambulance is generally not covered by the federal rules.
- For protected care, you generally owe only what you would pay in network, and it counts toward your in-network deductible and out-of-pocket max.
- Doctors like anesthesiologists, radiologists, pathologists and lab services can't ask you to give up these protections.
- Uninsured or self-pay? You have a right to a Good Faith Estimate, and a federal dispute if the bill is $400 or more above it.
- Report problems to the No Surprises Help Desk at 1-800-985-3059 or online through CMS.
You went to an in-network hospital. Weeks later, a bill shows up from a doctor you never chose, at out-of-network prices. Before 2022, you often had to pay it. Now federal rules limit it.
The No Surprises Act took effect for care on or after January 1, 2022. Here is what it covers, how to tell if your bill breaks the rules, and what to do next.
What does the No Surprises Act protect?
For most people with private health insurance, the federal rules limit surprise out-of-network bills in three situations:
| Situation | What you generally owe |
|---|---|
| Emergency care, even at an out-of-network hospital or from out-of-network doctors | Your in-network cost-sharing only |
| Non-emergency care from out-of-network providers at an in-network hospital or surgery center | Your in-network cost-sharing only, unless you validly agreed in advance (see below) |
| Air ambulance from an out-of-network provider | Your in-network cost-sharing only |
| Ground ambulance | Generally not protected by the federal rules, unless your state has its own protections |
For emergency care, your plan can't require prior authorization, can't charge you more than in-network cost-sharing, and must count what you pay toward your in-network deductible and out-of-pocket maximum.
Can a doctor make me sign away my protections?
Sometimes, for planned care, an out-of-network provider can ask you to sign a notice and consent form agreeing to pay out-of-network rates. Strict limits apply.
- If you scheduled at least 72 hours ahead, they must give you the notice at least 72 hours before the service.
- If you scheduled less than 72 hours ahead, they must give it the day you schedule, and no later than 3 hours before care.
- It can't be used for care given because of unforeseen, urgent medical needs.
Some providers can never ask you to waive your protections at an in-network facility. These include emergency medicine, anesthesiology, pathology, radiology and neonatology, plus assistant surgeons, hospitalists, intensivists, and diagnostic services like lab work and imaging. The same goes when no in-network provider was available at the facility.
How do I know if my surprise bill breaks the rules?
- Check the EOB. Find the Explanation of Benefits for this provider. If the plan processed it as protected, the patient balance should reflect in-network cost-sharing. See how to compare an EOB to your bill.
- Check the type of care. Was it emergency care, air ambulance, or a provider at an in-network hospital?
- Check for a consent form. Did you sign a notice and consent form? Was it for a provider type that can't use one?
- Compare the bill to the EOB. If the provider bills you more than the EOB patient balance, that gap is often the surprise bill.
What should I say to the provider?
Start in writing. Send this to the billing office, and keep a copy.
“[Date] Re: Account [account number], patient [name], date of service [date] I received a bill for $[amount] for out-of-network services. I believe these services are protected by the No Surprises Act because [they were emergency services / they were provided at an in-network facility, [facility name], and I did not validly consent to out-of-network billing / they were air ambulance services]. Under these rules, I owe no more than my in-network cost-sharing, which my Explanation of Benefits from [insurer], claim number [claim number], lists as $[EOB amount]. Please correct the bill to that amount and hold the account from collections while you review it. Sincerely, [Your name, phone, email]”
Call your health plan too. Ask whether the claim was processed under No Surprises Act rules. If it wasn't, ask them to reprocess it.
What is a Good Faith Estimate?
If you are uninsured, or you have insurance but choose not to use it for a service, providers generally must give you a Good Faith Estimate of expected charges. The timing rules are:
| When you schedule | When you should get the estimate |
|---|---|
| At least 3 business days ahead | Within 1 business day of scheduling |
| At least 10 business days ahead | Within 3 business days of scheduling |
| You ask for one, without scheduling | Within 3 business days of your request |
“I'm paying for this myself and not using insurance. Before my appointment, please send me a written Good Faith Estimate of the expected charges, including any other providers or facilities that will be involved.”
How do I dispute a bill that's $400 over my estimate?
If you got a Good Faith Estimate and the final bill from a provider or facility is at least $400 more than its estimate, you can use the federal patient-provider dispute resolution process. An independent reviewer decides what you pay.
- Deadline: start within 120 calendar days of the date on the initial bill.
- Fee: a $25 administrative fee, which is not refundable. If the reviewer sides with you, the fee comes off what you owe.
- What you need: a copy of the Good Faith Estimate, the bill, and the provider's contact information. Don't mail originals.
- How to file: online through the CMS dispute portal, or by mail or fax with the federal dispute form.
While the dispute is open, the provider can't send the bill to collections, collect late fees on it, or retaliate against you. If it is already in collections, collection must pause. If you settle with the provider before a decision, the provider must cut the bill by at least $12.50.
How do I file a No Surprises Act complaint?
If a provider, facility or plan isn't following these rules, report it. Call the No Surprises Help Desk at 1-800-985-3059, or file online through CMS. Help is available in English, Spanish and more than 350 other languages.
- Have your bill, your EOB and a photo of your insurance card ready.
- The online form resets after 15 minutes of inactivity, so gather everything first.
- Write down your confirmation number. CMS says it will contact you within 60 days if it needs more information.
Your state may have its own surprise billing rules, especially for ground ambulance. Contact your state insurance department to ask. If you live in Wyoming, start with Wyoming's medical bill rules. For a plain list of all your federal rights, see your rights.
Ahem flags bills that look like protected surprise bills and drafts the letter for you to sign and send. Start a free scan.
Common questions
Does the No Surprises Act cover ground ambulance bills?
Generally, no. The federal balance billing protections cover air ambulance services from out-of-network providers, but ground ambulance services are generally not covered, so providers can still bill out-of-network rates. Some states have their own ground ambulance protections. Contact your state insurance department to ask what applies where you live.
How long do I have to dispute a bill that's higher than my Good Faith Estimate?
You must start the federal patient-provider dispute within 120 calendar days of the date on the initial bill. The bill must be at least $400 more than that provider's or facility's Good Faith Estimate, and there is a $25 administrative fee. Keep a copy of the estimate, because you need it to file.
What if I signed a consent form to pay out-of-network rates?
Check whether it counted. Notice and consent forms can't be used for emergency care, for care due to unforeseen urgent needs, or for certain providers at in-network facilities, including anesthesiology, radiology, pathology, emergency medicine, neonatology, hospitalists, intensivists, assistant surgeons and lab services. Timing rules also apply. If any of these fit, the protections may still apply.
Does the No Surprises Act apply to Medicare or Medicaid?
CMS describes these balance billing protections as applying to most people with private health insurance. Medicare and Medicaid are separate programs with their own billing rules, which this guide does not cover. If you have Medicare or Medicaid and get an unexpected bill, call the number on your card or the No Surprises Help Desk to ask.
Sources
- Your rights and protections against surprise medical bills · CMS
- Dispute a medical bill (patient-provider dispute resolution) · CMS
- Submit a complaint · CMS
- 45 CFR 149.110: Preventing surprise medical bills for emergency services · Cornell LII
- 45 CFR 149.420: Notice and consent exception · Cornell LII
- 45 CFR 149.610: Good faith estimates for uninsured or self-pay individuals · Cornell LII
- Know your rights and protections when it comes to medical bills and collections · CFPB
Ahem is a self-help tool. It is not a law firm, a medical provider, or an insurer. This guide is general information, not advice about your situation. Rules change; we recheck each guide and show the date above. Spot an error? Tell us.