What Is Balance Billing, and When Is It Not Allowed?

Written by Aptiva Health Editorial Team · Reviewed by Crystal Brake, RCM Director and Taylor Sorrels, Esq. · Editorial & review standards · How we research

Balance billing is when a provider bills you for the difference between what it charges and what your health plan allows (HealthCare.gov: Balance billing).

Here is an example from HealthCare.gov. A provider charges $100. Your plan’s allowed amount is $70. The provider bills you for the other $30. That $30 is a balance bill. It is on top of your normal deductible, copay or coinsurance.

Some balance bills are allowed. Many are not. This guide explains the difference and what to do if you get one. It is part of the Coverage & Appeals Center.

Words to know

• In network: the provider has a contract with your plan.
• Out of network: the provider has no contract with your plan.
• Allowed amount: the most your plan will pay for a covered service.
• Cost sharing: your share of the bill, such as a deductible, copay or coinsurance.
• Surprise bill: an unexpected balance bill, often from an out-of-network provider you didn’t choose (KY DOI bulletin).

When balance billing is NOT allowed

In-network care

In-network providers agree with the insurance company to accept the insurance payment in full, apart from your cost sharing (KY DOI bulletin). HealthCare.gov says the same: preferred providers may not balance bill you for covered services (HealthCare.gov).

Emergency care (No Surprises Act)

The federal No Surprises Act protects you from surprise bills for emergency room visits (CMS: Medical bill rights). For emergency services, an out-of-network hospital or doctor may not bill you more than your in-network deductible, copays or coinsurance (KY DOI bulletin).

Certain care at an in-network hospital or surgery center

The No Surprises Act also covers non-emergency care related to a visit to an in-network hospital, hospital outpatient department or ambulatory surgical center (CMS). An out-of-network provider there, such as an anesthesiologist, may not bill you more than your in-network cost sharing for covered services (KY DOI bulletin).

Air ambulance

The No Surprises Act covers air ambulance services (CMS). You pay only what you would pay if the air ambulance were in network (KY DOI bulletin).

These protections apply to employer self-funded plans as well as plans from insurance companies (KY DOI bulletin). See also out-of-network denials.

Medicare: providers who accept assignment

If your provider accepts assignment, it takes the Medicare-approved amount as full payment. It can charge you only the Medicare deductible and coinsurance (Medicare.gov). See Original Medicare.

Medicaid

Providers who take Medicaid must accept the Medicaid payment, plus any deductible, coinsurance or copay the program requires, as payment in full (42 CFR 447.15). See Medicaid managed care.

When the plan’s directory was wrong

If you relied on wrong information in your plan’s provider directory, the plan must limit your cost sharing to in-network amounts (KY DOI bulletin). Save a screenshot or printout of the directory page.

When balance billing MAY be allowed

You chose an out-of-network provider

Some plans, such as PPO or POS plans, pay part of out-of-network care, but the provider may still balance bill you. Other plans don’t cover out-of-network care at all, and you may owe the whole bill (KY DOI bulletin).

You signed a notice and consent form

In some cases, an out-of-network provider at an in-network facility can ask you to give up your No Surprises Act protections in writing. The rules are strict (45 CFR 149.420):

• Timing. You must get the notice at least 72 hours before the care. If you schedule the care less than 72 hours ahead, you must get it at least 3 hours before.
• An estimate. The notice must include a good faith estimate of what the provider may charge.
• Your choice. Consent must be voluntary, without pressure. You must get a copy of what you signed.
• You can change your mind. The consent counts only if you have not revoked it in writing before the care.

Some care can never be waived. You can’t be asked to give up your protections for emergency medicine, anesthesiology, pathology, radiology, neonatology, assistant surgeons, hospitalists, intensivists, or diagnostic services such as lab and radiology at an in-network facility (KY DOI bulletin; 45 CFR 149.420). It also doesn’t apply to care for unforeseen, urgent needs that come up during your care (45 CFR 149.420).

After an emergency. Once you are stable, an out-of-network provider may ask you to consent to more care at higher prices. They can ask only when you are stable, able to understand the information, and able to travel safely to an in-network facility by non-emergency transport (KY DOI bulletin).

Ground ambulance

The No Surprises Act covers air ambulance, but not ground ambulance (KY DOI bulletin). Some states have their own ground ambulance rules. See the Kentucky and Indiana sections below.

Medicare providers who don’t accept assignment

Providers who don’t accept assignment can charge more than the Medicare-approved amount. In many cases, the charge can’t be more than 15% above that amount (Medicare.gov). If a doctor has opted out of Medicare, Medicare won’t pay except in emergencies, and you may pay through a private contract (Medicare.gov).

Kentucky

• Federal protections apply. The Kentucky Department of Insurance explains the No Surprises Act protections in its consumer bulletin (KY DOI bulletin).
• Ground ambulance. Bills to ban balance billing by out-of-network emergency ground ambulance providers were filed in 2025 (HB 245) and 2026 (HB 447). The Legislative Research Commission’s records show neither passed; both stopped in the House Banking & Insurance Committee (2025 HB 245; 2026 HB 447).
• Help: Kentucky Department of Insurance, Division of Consumer Protection: 800-595-6053, Option 1 (in Kentucky only), or 502-564-6034 (KY DOI).

Indiana

• Federal protections apply. The State of Indiana says the No Surprises Act is “enforced by the federal government in Indiana” (Indiana: No Surprises Act). The same page notes that state laws don’t apply to self-insured employer plans (Indiana).
• Indiana law. Indiana may have its own rules for out-of-network bills. Check with your plan or the Indiana Department of Insurance.
• Help: Indiana Department of Insurance Consumer Services: 800-622-4461 or 317-232-2395 (IDOI).

What to do if you get a balance bill

1. Don’t pay yet. Check first whether the bill is allowed.
2. Get the EOB. Compare the bill with what your plan says you owe.
3. Get an itemized bill. Check each line. See how to get an itemized bill.
4. Ask: was it protected care? Emergency care, care at an in-network hospital or surgery center, or air ambulance? Did you sign a consent form?
5. Call the provider’s billing office. Say why you think the bill isn’t allowed. Ask them to correct it and to hold the account.
6. Call your plan. Ask whether the claim was processed under the No Surprises Act. If the plan denied or underpaid it, you may be able to appeal. Use the appeal deadline calculator.
7. Get outside help. Call the No Surprises Help Desk at 1-800-985-3059 or file a complaint online (CMS). You can also contact your state insurance department.

Your sample letter

[Your name]
[Your address] · [Your phone] · [Your email]

[Date]

[Provider name] — Billing Office
[Address or fax from your bill]

RE: Dispute of balance bill
Patient name: [Name]
Account number: [Number]
Date(s) of service: [Date or dates]
Health plan: [Plan name] · Member ID: [Number]
Claim number (from EOB): [Number]

To the Billing Office:

I received a bill for $[amount] for the care listed above. My Explanation of Benefits says I owe $[amount]. I believe the difference, $[amount], is a balance bill that is not allowed.

[Choose the reasons that apply:]
- This was emergency care. Under the federal No Surprises Act, I owe no more than my in-network cost sharing.
- This care was at an in-network [hospital / outpatient department / surgery center], [facility name]. I did not sign a notice and consent form [or: the care was [anesthesiology / radiology / lab / other], which can't be waived].
- This was an air ambulance service.
- You are in network with my plan.
- I have Medicaid. You accepted Medicaid payment for this care.
- [Medicare:] You accept Medicare assignment.

Please correct my bill to $[amount from EOB], and send me a corrected statement. Please hold my account and do not send it to collections while you review this.

Enclosed:
- My EOB
- Your bill
- [Directory printout / other proof]

You can reach me at [phone] or [email].

Sincerely,
[Signature]
[Printed name]

The appeal letter builder can help if your plan also needs an appeal.

Common mistakes

• Paying a surprise bill before you check your rights. Ask questions first.
• Signing a consent form without reading it. You can say no. Ask for an in-network provider instead.
• Thinking every ambulance is covered. Federal protections cover air ambulance, not ground ambulance.
• Not comparing the bill with the EOB. The EOB shows what your plan says you owe.
• Mixing up a balance bill and a denial. If your plan denied the claim, you may need to appeal to the plan, too.

Questions about an Aptiva bill?

If you are an Aptiva patient and you think a bill includes a balance bill, contact our billing team.

For a denied claim, start at the Coverage & Appeals Center.