The No Surprises Act Explained

What the No Surprises Act is

The No Surprises Act is a federal law that took effect January 1, 2022. It was enacted to address one of the most common and financially devastating problems in American healthcare: patients receiving large bills from out-of-network providers they never chose — most commonly in emergency situations or during care at in-network facilities.

The law is administered jointly by the Centers for Medicare & Medicaid Services (CMS), the Department of Labor, and the Department of the Treasury. Full guidance, including consumer protections and the dispute resolution process, is available at cms.gov/nosurprises.

What the law prohibits

The No Surprises Act creates three categories of protection:

Emergency services at any facility

When you receive emergency services at any hospital emergency department — regardless of whether the facility or any of the providers treating you are in your insurance network — you cannot be billed more than your in-network cost-sharing amount. This means your deductible, copayment, or coinsurance based on in-network rates applies, even if every physician who treated you was out-of-network.

This protection applies retroactively to any emergency service. You did not choose your emergency room physician. The law recognizes this and prohibits out-of-network billing regardless of who treated you during the emergency.

Non-emergency services at in-network facilities

When you receive non-emergency care at an in-network facility, out-of-network providers at that facility cannot balance bill you unless they obtained your written informed consent — using a specific required disclosure form — at least 72 hours before your appointment, or on the day of service for appointments scheduled that day with less than 72 hours notice.

This consent requirement is significant. Most patients in this situation never received the required disclosure. The anesthesiologist assigned to your surgery did not hand you a written disclosure. The radiologist who read your imaging did not obtain your consent. Without that specific written document, their balance bill violates the law.

Air ambulance services

For patients covered by participating insurance plans, air ambulance providers cannot charge more than the in-network cost-sharing amount, regardless of the air ambulance provider's network status. Given that air ambulance bills commonly range from $30,000 to over $100,000, this protection is particularly significant.

The 120-day dispute window

Your right to initiate a formal dispute under the No Surprises Act runs from the date of your Explanation of Benefits — not the date of service or the date you received the bill. You have 120 days from your EOB date to initiate the federal Independent Dispute Resolution (IDR) process.

This deadline is not extended by time spent negotiating with the provider's billing department or waiting for a corrected bill. Every day that passes without a formal dispute reduces the time remaining to exercise your federal rights. If the deadline passes, the federal IDR process is no longer available.

The federal IDR process is initiated through the CMS portal and involves an independent arbitrator who determines the appropriate payment amount. Patients can also file complaints directly with HHS through the No Surprises Help Desk at 1-800-985-3059.

Who the law covers — and who it doesn't

The No Surprises Act applies to most employer-sponsored health plans, individual and small group market plans, and Medicare Advantage plans. It does not apply to traditional Medicare (which has its own billing rules), Medicaid, or grandfathered health plans (plans that have not made significant changes since the ACA was enacted in 2010).

For services received before January 1, 2022, the No Surprises Act does not apply. However, many states enacted their own balance billing protections before the federal law — including New York, California, Texas, and Florida. KFF maintains a state-by-state tracker of balance billing protections that shows which laws apply in your state.

The Good Faith Estimate requirement

A related provision of the No Surprises Act requires providers and facilities to give uninsured or self-pay patients a Good Faith Estimate of expected charges before scheduled services. If the final bill exceeds the Good Faith Estimate by more than $400, the patient has the right to dispute the charges through a Patient-Provider Dispute Resolution process.

Common violations and how to identify them

The most common No Surprises Act violations involve emergency physician staffing companies. These companies — which manage emergency department physician coverage at many hospitals — are frequently out-of-network with major insurers. Before 2022, they routinely billed patients at out-of-network rates. After January 1, 2022, this practice is prohibited for emergency services covered by the law.

If you received a bill from a physician group name you don't recognize following an emergency room visit — typically the group's name rather than the hospital's name — this is the most common source of No Surprises Act violations. Check whether your insurer processed the associated claim at in-network rates. If they didn't, contact your insurer to request reprocessing under the No Surprises Act.

Received a surprise bill after January 2022? Get a free consultation — the 120-day window may still be open and our case managers act immediately.

What to do if you received a prohibited bill

First, contact your insurer and request that the claim be reprocessed under the No Surprises Act. Provide the specific claim number, the date of service, and identify the out-of-network provider. Most insurers have a No Surprises Act compliance team and will reprocess compliant claims without escalation.

If your insurer does not resolve the issue, file a complaint with HHS through the No Surprises Help Desk and simultaneously file a formal dispute with the provider. Include your EOB showing incorrect processing, a statement citing the specific No Surprises Act provision being violated, and a request for the account to be placed on hold during the dispute period.

For bills involving the federal IDR process, the dispute must be initiated at federalindependentdisputeresolution.com within 120 days of your EOB.