Your Rights And Protections Against Surprise Medical Bills

What Is Balance Billing

When you receive medical services, you may be responsible for costs such as copayments, coinsurance, or deductibles.

If you receive care from a provider outside your health plan’s network, that provider may bill you for the difference between what your plan pays and the total charge. This is known as balance billing.

This amount can exceed standard in-network costs and may not apply toward your deductible or out-of-pocket limit.

What Is Surprise Billing

Surprise billing is a form of balance billing that occurs when you do not have control over who provides your care.

This may happen during an emergency or when you receive treatment at an in-network facility but are seen by an out-of-network provider.

These charges can be unexpected and, in some cases, significant.

When You Are Protected

Emergency Services

If you receive emergency care from an out-of-network provider or facility, you cannot be charged more than your in-network cost-sharing amount.

This includes services received after your condition has stabilized, unless you provide written consent to waive these protections.

Services at In-Network Facilities

If you receive care at an in-network hospital or ambulatory surgical center, some providers involved in your care may still be out-of-network.

In these cases, those providers cannot charge more than your in-network cost-sharing amount for services such as:

• Emergency medicine
• Anesthesia
• Radiology
• Pathology
• Laboratory services
  
  

They are not allowed to ask you to give up your protections.

When Protections Cannot Be Waived

You are not required to give up your protections against balance billing.

You also have the right to choose in-network providers and facilities whenever possible.

Additional Patient Protections

When balance billing is not allowed:

• You are responsible only for your in-network cost-sharing amount
• Your health plan pays any remaining balance directly to the provider
• Payments count toward your in-network deductible and out-of-pocket limit
  
  

Your health plan must also:

• Cover emergency services without prior authorization
• Cover out-of-network emergency care
• Base your costs on in-network rates
  
  

If You Have Been Billed Incorrectly

If you believe you have been incorrectly billed, contact our office directly:

Comprehensive Pain Solutions of New Jersey
Phone: (855) 830-0999

You may also contact the federal No Surprises Help Desk:
1-800-985-3059

For additional information, visit:
https://www.cms.gov/nosurprises/consumers