Surprise Billing

Your Rights and Protections Against Surprise Medical Bills

You are protected from surprise billing or balance billing. You’re never required to give up your protections from balance billing or get care out-of-network. You can choose a provider or facility in your plan’s network. 

When you get emergency care or schedule a visit at in-network hospital or ambulatory surgical center but are unexpectedly treated by an out-of-network provider. 

What is “balance billing” (sometimes called “surprise billing”)?

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care. When you choose to see a doctor or health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have to pay higher cost up to entire bill if the provider is out-of-network 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 “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

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’s in-network cost-sharing amount (such as copayments and coinsurance). Unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services, you can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition.

Certain services at an in-network hospital/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’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If balance billing isn’t allowed, you are still Protected!

• 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. 

If you believe you’ve been wrongly billed, you may contact compliance@nashvilleha.org

Visit https://www.cms.gov/nosurpises for more information about your rights under federal law. 

Visit https://www.capitol.tn.gov/Bills/110/Bill/SB2640.pdf for more information about your rights under TN State law.