My emergency room visit was denied. What now?

Can my insurance deny my ER visit because it turned out not to be an emergency?

Federal guidance on surprise billing defines an emergency medical condition using a "prudent layperson" standard: a person with typical knowledge of health and medicine has a condition (including a mental health condition or substance use disorder) so severe they believe they need immediate care, and that waiting could put their health in serious jeopardy or seriously harm a body function or organ.

That definition looks at the symptoms you had and what you reasonably believed, so if your letter says the visit was "not an emergency," describing your symptoms that day is a strong place to start your appeal. How your plan applies this depends on your plan type, so check the reason and rules printed on your letter. This is general information, not legal or medical advice.

Does my insurance have to approve the ER visit first, or does it matter that the hospital was out of network?

For most private plans, HealthCare.gov says plans cannot require prior approval before you get emergency room services from an out-of-network hospital or provider, and cannot charge higher copayments or coinsurance because the emergency room was out of network.

HealthCare.gov says those particular rights do not apply to plans created or bought before March 23, 2010 (grandfathered plans). Separately, the federal No Surprises Act protections for emergency care generally do apply to grandfathered plans. You may still owe your plan's normal deductible, copay or coinsurance.

How do I appeal a denied emergency room claim?

For most private health plans, you can appeal in four steps. If you have Medicare or Medicaid, your steps are different: your plan must tell you in writing how to appeal, so follow the instructions on your notice. Keep copies of everything you send.

• Step 1: Read the denial letter. Find the reason given, the claim number, and the date on the letter. For private plans, your appeal deadline is counted from when you receive the notice.
• Step 2: Call your plan and take notes. Ask what is needed for an appeal and whether they have a form. Write down the date, time and name of each person you speak with.
• Step 3: Send a written internal appeal. Fill out your plan's forms, or write a letter with your name, claim number and health insurance ID number. Add a short account of your symptoms that day and any letter from the ER doctor saying why you needed care. HealthCare.gov says you have 180 days (6 months) from receiving the denial notice.
• Step 4: Ask for an outside review if they say no. You can ask an independent reviewer to look at it. HealthCare.gov says the request is due within 4 months after you receive the final decision, and your insurer is required by law to accept the reviewer's decision.

How long do I have to appeal, and how long will the plan take?

For private health plans, HealthCare.gov says you must file an internal appeal within 180 days (6 months) of receiving notice that your claim was denied. For care you have already received, like an ER visit, the internal appeal must be completed within 60 days.

For an outside (external) review, the request is due within 4 months after you receive the final decision, and standard reviews are decided no later than 45 days after the request is received. Medicare and Medicaid use different appeal steps and deadlines, and your own plan's letter may list specific dates, so follow the dates printed on your notice.

What are surprise billing protections for ER visits?

When the No Surprises Act applies, it protects you from surprise out-of-network bills for most emergency services, including care after you are stabilized, at an out-of-network ER or from an out-of-network provider. Your out-of-network cost sharing cannot be higher than your in-network cost sharing, but you can still owe your plan's normal deductible, copay or coinsurance.

If you think you were billed wrongly, you can call the No Surprises Help Desk at 1-800-985-3059.

Does my type of insurance change my rights?

Yes. The No Surprises Act covers employer group health plans, individual or group coverage bought on or off the Marketplace, state and local government plans, church plans, federal employee (FEHB) plans and fully insured student plans. It does not cover short-term plans, health care sharing ministries, or stand-alone dental or vision plans.

If your coverage is only through Medicare (including Medicare Advantage), Medicaid, CHIP, Indian Health Service, VA health care or TRICARE, the No Surprises Act does not apply, but CMS says those programs already have certain protections against balance billing. For free help with Medicare, you can contact your State Health Insurance Assistance Program (SHIP). Ground ambulance rides are not covered by the No Surprises Act, though other remedies may exist.

Your checklist

• Find the date on your denial letter and write down the appeal deadline
• Check what kind of plan you have: employer, Marketplace, Medicare, Medicaid or other
• Circle the reason the plan gave for denying the visit
• Write what you felt and feared that day, in your own words
• Ask the ER doctor for a short letter on why you needed care
• Gather the bill, the denial letter and your member ID in one folder
• Call your plan, and note the date, time and name of each person
• Send your appeal in writing and keep a copy

A letter you can copy

[Your full name] [Your address] [Date] [Health plan name] Attn: Appeals [Plan address from your denial letter] Re: Appeal of denied emergency room claim Member ID: [Member ID] Claim number: [Claim number] Date of service: [Date of ER visit] Hospital: [Hospital name] To the Appeals Department: I am appealing the denial of my emergency room claim dated [date of denial letter]. Your letter says the reason for denial was: [reason given]. On [date], I went to the emergency room because [describe your symptoms and what you feared]. I believed, as a person with typical knowledge of health would, that I needed immediate care and that waiting could seriously harm my health. I ask that you judge this visit on the symptoms I had when I arrived, not only on the final diagnosis. I ask that you reverse this denial and process the claim. I have enclosed: [denial letter, bill, letter from my doctor, other records]. Please send your written decision to the address above. Sincerely, [Your name] [Phone number]

Which rules apply to you?

The steps and deadlines on this page can differ by the kind of plan you have. Your own denial letter always comes first.

• Coverage through a job:ask your HR team whether the plan is “self-funded” or “fully insured.” It can change who you can ask for help. Most private-sector job plans fall under a federal law called ERISA, and the U.S. Department of Labor’s EBSA takes health plan questions at Ask EBSA or 1-866-444-3272.
• Marketplace plan: follow the appeal steps at HealthCare.gov.
• Medicare or Medicaid: each has its own appeal process, listed on your notice.
• Dental-only plan: your plan contract sets the appeal rights, so read it and your letter.

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Free tools for the next step

Keep your appeal papers in one place. Take a photo of your denial letter, EOBs and insurance cards with GetPreCare, so they are on your phone when the insurer or the office asks. Free. Open GetPreCare. Helping a parent or partner? Set it up for them.