Out-of-network emergency billing
No Surprises Act — emergency billing appeal
ER visits, ambulance, or ancillary services billed OON despite No Surprises Act protections.
Use this letter to formally appeal a "out-of-network emergency billing" denial. Replace every {{PLACEHOLDER}} with your own facts, attach the listed evidence, and send it certified mail plus by the insurer's online portal.
Template
{{MEMBER_NAME}}
{{MEMBER_ADDRESS}}
{{MEMBER_PHONE}}
Member ID: {{MEMBER_ID}}
Claim / Reference #: {{CLAIM_NUMBER}}
Date of Service: {{DATE_OF_SERVICE}}
Date of Denial Notice: {{DENIAL_DATE}}
{{INSURER_NAME}}
Appeals and Grievances Department
{{INSURER_APPEAL_ADDRESS}}
Re: Formal Internal Appeal — {{CLAIM_NUMBER}}
I am appealing your processing of {{CLAIM_NUMBER}} for emergency services rendered on {{DATE_OF_SERVICE}} at {{FACILITY}}.
Under the No Surprises Act (Public Health Service Act §2799A-1 and implementing rules at 45 CFR 149), out-of-network emergency services must be:
• Covered without prior authorization;
• Reimbursed with in-network cost-sharing applied to the recognized amount; and
• Not balance-billed to me.
Please reprocess the claim so that my cost-sharing reflects in-network levels and correct any balance-billed amounts.
Sincerely,
{{MEMBER_NAME}}Key points before you send it
- You cannot be balance-billed for out-of-network emergency care.
- Cost-sharing must be calculated as if the service were in-network.
Want this pre-filled with your denial details?
Upload your letter — we'll parse it and generate this template with your facts, dates, and clinical evidence already in place.
Not legal or medical advice. This page is a self-help resource. You make your own decisions. Strip personal identifiers (name, date of birth, address, member ID) from any document before uploading or sharing. The information here summarizes commonly-published payer policies and federal rules; confirm against your specific plan document and the current denial letter before acting.