Medical billing
No Surprises Act (federal balance-billing protections)
NationalUSRead off primary law
United States (federal)
- Rule id
- medical.us-nsa
- Version
- 1.0.0
- In force from
- January 1, 2022
- Last read against its sources
- August 5, 2026
- Countries bound
- United States
In plain language
What this regime says.
The No Surprises Act stops a provider billing you above your in-network cost sharing in four situations: emergency care anywhere, post-stabilisation care until you are genuinely able to leave, non-emergency care from an out-of-network clinician inside an in-network facility, and out-of-network air ambulance. It does not cover ground ambulance, and it does not cover planned care you chose to have at an out-of-network facility.
Who is covered
People with a group health plan, or individual or group health insurance coverage, including self-funded employer plans and the Federal Employees Health Benefits programme. It does not apply to Medicare, Medicaid, TRICARE, Indian Health Service or Veterans Affairs care — those have their own, generally stronger, rules — and it does not apply to short-term limited-duration insurance or to health care sharing ministries. Uninsured and self-pay patients are protected by the separate good-faith-estimate route.
What you get
Cost sharing calculated as if the care had been in network and counted toward your in-network deductible and out-of-pocket maximum; the balance above that removed from the bill; a refund of anything already paid above it; and a federal complaints process. The provider's argument with your plan is settled between them by independent dispute resolution, without you.
Where claims go wrong
- Assuming ground ambulance is covered. Congress left it out and created an advisory committee instead; state law is the only route.
- Assuming a signed consent form ends the matter. For emergency services and for the whole ancillary list — anaesthesiology, radiology, pathology, neonatology, assistant surgeons, hospitalists, intensivists and diagnostics — consent is void as a matter of law.
- Paying the balance to stop the calls, and only then asking whether it was owed.
- Reading "the plan underpaid us" as a statement about your liability. It is a statement about the provider's dispute with the plan, which the statute keeps away from you.
- Being uninsured and writing the balance-billing letter. The good-faith-estimate and dispute-resolution route is the one that fits.
Authority
Every citation,
with its pinpoint.
A claim that cites “EU law” gets filed. A claim that cites Article 7(1)(c) gets answered. These are the exact coordinates this entry rests on.
- PHS Act § 2799A-1(a), 42 U.S.C. § 300gg-111(a)Public Health Service Act, as added by the No Surprises Act (Division BB, Title I, Consolidated Appropriations Act, 2021, Pub. L. 116-260)URL verified 2026-08-05§ 2799A-1(a)(1)(C) — emergency services must be covered without prior authorisation, without regard to whether the provider or facility participates, and with cost sharing calculated as if the services had been furnished in network
- PHS Act § 2799A-1(b), 42 U.S.C. § 300gg-111(b)Public Health Service Act, as added by the No Surprises ActURL verified 2026-08-05§ 2799A-1(b) — non-emergency items and services furnished by a non-participating provider at a participating health care facility
- PHS Act § 2799A-2, 42 U.S.C. § 300gg-112Public Health Service Act, as added by the No Surprises ActURL verified 2026-08-05§ 2799A-2 — cost sharing for out-of-network air ambulance services must be no greater than it would have been in network
- PHS Act § 2799B-2, 42 U.S.C. § 300gg-132Public Health Service Act, as added by the No Surprises ActURL verified 2026-08-05§ 2799B-2 — a non-participating provider or facility shall not bill, and shall not hold liable, a participant, beneficiary or enrollee for more than the in-network cost-sharing amount
- 45 CFR § 149.420Requirements Related to Surprise Billing, 45 CFR Part 149 Subpart EURL verified 2026-08-05§ 149.420(b) — items and services for which notice and consent may never be sought; § 149.420(c) — unforeseen urgent medical needs; § 149.420(e) — timing (72 hours, or 3 hours for a same-day appointment); § 149.420(d), (f)-(g) — form, language, separate document, signature and retention requirements
- PHS Act § 2799B-4, 42 U.S.C. § 300gg-134Public Health Service Act, as added by the No Surprises ActURL verified 2026-08-05§ 2799B-4(b) — civil money penalties of up to $10,000 per violation; § 2799B-4(b)(3) — no penalty where the provider did not knowingly violate and, within 30 days of the violation, withdraws the bill and reimburses the individual with interest
Sources
Where a figure is indexed, converted or published by a regulator rather than fixed in the instrument, the provenance is recorded separately. Anything marked as a modelled estimate is exactly that — a model, not a statutory number.
- No Surprises Act — CMS consumer and provider guidance, and the No Surprises Help DeskCenters for Medicare & Medicaid Servicesretrieved 2026-08-05
- Requirements Related to Surprise Billing, 45 CFR Part 149Electronic Code of Federal Regulationsretrieved 2026-08-05
What it imposes
Clocks, defences and the ladder.
A rule module builds these while it evaluates, because a limitation period depends on which forum is open to you. What follows is the structure this regime produces — deliberately with no dates and no figures, because those belong to your facts rather than to the law.
Where to take it next
- Ask for the good faith estimate you should have been givenBefore anything else, ask the provider in writing for the good faith estimate it was required to give you under 45 CFR § 149.610, and for the fully itemised bill. If no estimate was ever issued, that is itself a violation and it is the first thing to put in the letter.Claim directtypically 14 days
- Written dispute to the provider's billing officeDispute in writing, not by phone, and keep proof of sending. Name the statute, ask for the bill to be withdrawn or corrected to the lawful amount, ask for the fully itemised statement with its codes, and give a date by which you expect a reply. Say expressly that the account is disputed — that single sentence changes what a collector may lawfully do next.Claim directtypically 30 days
- Appeal to the health plan and demand the claim fileWhere a plan is involved, appeal the adverse determination and ask, in the same letter, for the complete claim file free of charge. For an employer plan that is a right under 29 CFR § 2560.503-1(h)(2)(iii), and the file usually contains the document that decides the dispute.Internal appealtypically 60 days
- Complaint to the CMS No Surprises Help DeskThe federal complaints process under 45 CFR § 149.450 takes consumer complaints about surprise billing and good-faith-estimate failures, and routes them to whoever holds enforcement — the state, or CMS where the state does not enforce. It is free, and a provider that has been asked to explain itself to CMS behaves differently. The Help Desk line is 1-800-985-3059.Regulatortypically 60 daysofficial page
- Complaint to your state insurance regulator or attorney generalState insurance departments enforce state balance-billing law against insurers and, in many states, run the arbitration that settles what the plan owes the provider. State attorneys general take the provider-side complaints that insurance regulators cannot. Both are free and can be run alongside the federal complaint.Regulatortypically 90 days
- Complaint to the Consumer Financial Protection BureauOnce a medical bill is with a collection agency the Fair Debt Collection Practices Act applies to the agency, and the CFPB takes complaints about collectors and about credit reporting. It requires a substantive response, usually within 15 days, and it is the fastest route to getting a disputed medical tradeline looked at.Regulatortypically 60 daysofficial page
- Small-claims or state consumer-protection actionWhere the provider will not move and the sum is within the small-claims limit, a filing fee of roughly USD 30-100 buys a hearing without a lawyer. Most state unfair-and-deceptive-practices statutes also reach a demand for money that is not owed, and several carry fee-shifting, which is what makes a modest medical claim worth a lawyer's time.Small claimstypically 120 days
Documents
What this regime can produce.
Every one of these is a document you send yourself, in your own name. Duesday never writes to anybody on your behalf and is never anyone’s agent.
The same claim type elsewhere
EU cross-border healthcare — Directive 2011/24/EU reimbursement, the EHIC and the S2EUSupranational — 27 countriesDirective 2011/24/EU, Arts. 6, 7 and 8Confidence: highFrance — dépassements d'honoraires, secteur 1 and 2, and the OPTAMFRNational — FranceCode de la santé publique, art. R. 4127-53Confidence: mediumGermany — the GOÄ and GOZ private billing schedules and their multiplier limitsDENational — GermanyGebührenordnung für Ärzte (GOÄ), §§ 2, 5 and 12Confidence: mediumIreland — public hospital charges, medical cards and the HSE complaints routeIENational — IrelandHealth Act 1970 (as amended)Confidence: lowItaly — Servizio Sanitario Nazionale, the ticket and the URP routeITNational — ItalyLegge 23 dicembre 1978, n. 833Confidence: lowNetherlands — NZa tariffs, the eigen risico and the SKGZ dispute routeNLNational — NetherlandsWet marktordening gezondheidszorg (Wmg), art. 35Confidence: mediumSpain — Sistema Nacional de Salud coverage and the right to economic informationESNational — SpainLey 41/2002, de autonomía del pacienteConfidence: lowUnited Kingdom — NHS charging, overseas visitor invoices and private healthcareGBNational — United KingdomNational Health Service Act 2006, s. 1(4)Confidence: medium
Other rights in the same countries
Alabama security deposit return — Ala. Code § 35-9A-201US-ALSub-national — United StatesAla. Code § 35-9A-201Confidence: mediumAlabama unclaimed property — Ala. Code §§ 35-12-70 to 35-12-99US-ALSub-national — United StatesAla. Code §§ 35-12-70 to 35-12-99Confidence: mediumAlaska security deposit return — Alaska Stat. § 34.03.070US-AKSub-national — United StatesAlaska Stat. § 34.03.070Confidence: mediumAlaska unclaimed property — Alaska Stat. §§ 34.45.110–34.45.780US-AKSub-national — United StatesAlaska Stat. §§ 34.45.110–34.45.780Confidence: mediumArizona security deposit return — A.R.S. § 33-1321US-AZSub-national — United StatesA.R.S. § 33-1321Confidence: highArizona unclaimed property — Ariz. Rev. Stat. §§ 44-301 to 44-341US-AZSub-national — United StatesAriz. Rev. Stat. §§ 44-301 to 44-341Confidence: mediumArizona surprise out-of-network bill dispute resolution (A.R.S. § 20-3111 et seq.)US-AZSub-national — United StatesA.R.S. § 20-3111 et seq.Confidence: mediumArkansas security deposit return — Ark. Code Ann. § 18-16-306US-ARSub-national — United StatesArk. Code Ann. § 18-16-306Confidence: medium
Does this one reach your facts?
The engine runs every regime that could apply at once and reconciles them, rather than making you guess which page to read.
Not a law firm. Not legal advice. You send it yourself. This page describes a law; it is not advice about your situation and no outcome is promised.