What Is "Balance Billing" (Sometimes Called "Surprise Billing")?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn鈥檛 in your health plan鈥檚 network.
鈥淥ut-of-network鈥 describes providers and facilities that haven鈥檛 signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called 鈥渂alance billing.鈥 This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
鈥淪urprise billing鈥 is an unexpected balance bill. This can happen when you can鈥檛 control who is involved in your care鈥攍ike when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
Protection From Balance Billing
You are protected from balance billing for:
Emergency Services
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan鈥檚 in-network cost-sharing amount (such as copayments and coinsurance). You can鈥檛 be balance billed for these emergency services. This includes services you may get after you鈥檙e in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain Services at an In-Network Hospital or Ambulatory Surgical Center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan鈥檚 in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can鈥檛 balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can鈥檛 balance bill you, unless you give written consent and give up your protections.
You鈥檙e never required to give up your protections from balance billing. You also aren鈥檛 required to get care out-of-network. You can choose a provider or facility in your plan鈥檚 network.
Protections When Balance Billing Is Not Allowed
When balance billing isn鈥檛 allowed, you also have the following protections:
You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
Wrongful Billing Contact Information
If you believe you鈥檝e been wrongly billed, you may contact:
91麻豆天美直播 Billing
Email: patientbilling@hsc.utah.edu
Phone: 801-587-6303 or 800-862-4937
Utah Insurance Department
Email: health.uid@utah.gov
Phone: 800-439-3805, 801-957-9280
The U.S Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Toll Free Call Center: 1-877-696-6775
Centers for Medicare and Medicaid Services CMS, Denver Regional Office Phone: 303-844-2111
Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.