What You Need to Know About Surprise Medical Bills and Prior Authorization

You are protected from surprise billing when you receive emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgery center. In these situations, you should not be charged more than your plan’s in-network cost-sharing amounts (such as copayments, coinsurance, or deductibles).

Your Protections Include:

  • You are only responsible for paying your in-network copayments, coinsurance, and deductibles.
  • Your health plan must:
    • Cover emergency services without requiring prior authorization.
    • Cover emergency care from out-of-network providers.
    • Base your cost-sharing on what it would pay in-network.
    • Count your out-of-network emergency care costs toward your in-network deductible and out-of-pocket maximum.

Understanding Surprise Medical Bills

When you receive care, you may be responsible for certain out-of-pocket costs such as a copayment, coinsurance, or deductible. However, if you are treated by a provider or facility that is not in your insurance network, you may face additional charges—this is known as balance billing.

Out-of-network providers can bill you for the difference between what your health plan pays and the full cost of the service. This amount is typically higher than in-network costs and often does not count toward your deductible or out-of-pocket maximum.

Surprise billing happens when you unexpectedly receive care from an out-of-network provider—such as
during an emergency or when you’re unknowingly treated by an out-of-network provider at an in-network
facility. These surprise bills can be significant.

When Surprise Billing Is Not Allowed

You are protected from balance billing in the following situations:

Emergency Services

If you receive emergency care from an out-of-network provider or facility, the most you can be billed is your in-network cost-sharing amount. This includes services received after you’re stabilized, unless you give written consent to waive your protections and agree to be billed by the out-of-network provider.

Prior Authorization and Care Management Limitations

Except in emergencies, your health plan may require prior authorization or apply other care management rules before covering certain items or services.

This means you may need to get approval from your plan in advance to ensure those services will be covered.

If your plan requires prior authorization, contact your insurance provider to confirm what information is needed to obtain approval and avoid unexpected costs.

What to Do If You Believe You Were Incorrectly Billed

  • Contact Shurmatz Counseling at 716-217-6112
  • You may also call the federal help line at 1-800-985-3059 or visit www.cms.gov/nosurprises/consumers to learn more about your rights under federal law.