Denied Because a Provider Was Out of Network? What to Do

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

Most health plans have a network: a list of doctors, hospitals and clinics that have a contract with the plan. When you get care from a provider outside that list, the plan may pay less, or nothing at all. The claim may come back marked “out of network.”

This kind of denial is not always the end of the story. Federal law protects you from many surprise out-of-network bills. Plans can also make mistakes about who is in network. And some plans make exceptions when no in-network provider could give you the care you needed.

This guide explains your rights, what to check, and how to appeal. It is part of the Coverage & Appeals Center.

What the letter says vs. what it means

Before you do anything else, find out which one you have. Call the plan, read the exact reason to the representative, and write down the answer and a reference number.

When federal law protects you

The No Surprises Act protects you from surprise out-of-network bills in three main situations (CMS: Medical bill rights):

• Emergency care, including at an out-of-network emergency room.
• Certain non-emergency care at an in-network hospital, hospital outpatient department or ambulatory surgical center, when a provider there is out of network.
• Air ambulance services.

For emergencies, plans must also cover emergency services without any prior authorization, even if the provider is out of network (45 CFR 149.110(b)(1)).

If your bill or denial falls into one of these groups, say so in your appeal. You can also call the No Surprises Help Desk at 1-800-985-3059 or file a complaint online (CMS: Submit a complaint).

What you owe in these cases, and when a provider may ask you to give up these protections in writing, depends on details of the law.

Billing disputes between your provider and your plan

Sometimes the fight is not really about you. An out-of-network provider and a plan may disagree about how much the plan should pay for care the No Surprises Act protects. They can use a federal process called independent dispute resolution (IDR). IDR is a payment dispute between the provider and the plan. It is not a patient appeal, and you do not file it (CMS: IDR Operations fact sheet).

New federal IDR rules took effect on August 3, 2026 (Federal Register, June 4, 2026). One change: for care on or after January 1, 2027, plans must use standard codes on payment notices to out-of-network providers to show whether the No Surprises Act applies. That should make it easier to tell when the protections cover your care.

When the protections may not apply

The No Surprises Act does not cover every out-of-network visit. If you chose an out-of-network provider for planned care, outside the situations above, your plan’s normal network rules usually apply.

Even then, you may have options:

• The plan’s network list was wrong. If the plan’s directory listed the provider as in network, keep a screenshot or printout.
• No in-network provider could do the care. Some plans grant a network exception (sometimes called a network gap exception) so out-of-network care is paid at the in-network level.
• You could not reach an in-network provider in a reasonable time or distance. This is a question of network adequacy.

In Indiana, a grievance can be about the “availability of providers,” as well as claims handling and payment (IC 27-8-28-6).

How to appeal an out-of-network denial

1. Mark your deadline. Find the appeal deadline on the denial letter or Explanation of Benefits (EOB) and put it on your calendar.
2. Check the network status. Ask the plan and the provider’s office whether the provider was in network on your date of service. Get the answer in writing if you can.
3. Check for No Surprises Act protection. Was it an emergency, care at an in-network hospital or surgery center, or an air ambulance? If so, say so in your appeal and call the Help Desk at 1-800-985-3059.
4. Gather proof. Save the provider directory page, referral, approval letter, or notes from calls with the plan. Write down dates and names.
5. Ask for a network exception. If no in-network provider could give the care, ask your clinician for a letter explaining why this provider was needed.
6. Write a short appeal letter. Use the template below and attach your proof.
7. Send it and keep proof. Use the method on the denial letter. Save the fax confirmation, mail receipt or portal screenshot.
8. Ask for outside help if the plan says no. See “When to escalate” below.

Not sure which route applies? Try the appeal route wizard or look up a code with the denial decoder.

Sample appeal letter

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

[Date]

[Plan name] — Appeals Department
[Address or fax from your denial letter]

RE: Appeal of out-of-network denial
Member name: [Name]
Member ID: [Number]
Claim / reference number: [Number]
Service: [Service] on [date]
Provider: [Name]
Date of denial letter: [Date]

To the Appeals Department:

I am appealing your decision to deny [or reduce] payment for [service] on [date] because the provider was "[copy the exact reason]."

[Choose the reasons that apply:]
- This was emergency care. Federal law requires coverage of emergency services without prior authorization, even out of network (45 CFR 149.110(b)(1)).
- This care was at an in-network [hospital / outpatient department / surgery center], [facility name]. I did not choose the out-of-network provider.
- Your provider directory listed [provider] as in network on [date]. A copy is enclosed.
- No in-network provider could give this care within a reasonable time or distance. I ask for a network exception. My clinician's letter explains why.

Enclosed:
- Your denial letter or EOB
- [Directory printout / referral / approval / call notes]
- Letter from [clinician]

Please reprocess this claim at the in-network level. If you do not, please tell me in writing the specific reason, the plan provision you relied on, and how to request an external review.

Sincerely,
[Signature]
[Printed name]

The appeal letter builder can help you fill in the blanks.

Deadlines

Use the appeal deadline calculator to count the days. See the Kentucky and Indiana guides for state steps.

When to escalate

External review. Not every network denial qualifies for an outside review. Under the federal rules, external review covers denials that involve medical judgment. It also covers whether a plan followed the No Surprises Act’s surprise-billing and cost-sharing protections (45 CFR 147.136(d)). If your denial involves a protected emergency, in-network facility or air ambulance service, ask the plan how to request external review.

Kentucky. Out-of-network denials are not the main kind of decision Kentucky’s independent review covers. You can take them to the Department of Insurance as a complaint (KY DOI: Appealing a Denial). Complaints must be in writing.

Indiana. Grievances about provider availability and claims payment go through the insurer’s internal process. Indiana’s external review covers medical necessity, appropriateness and experimental denials, plus rescissions (IC 27-8-29-12).

Self-funded employer plans. State insurance departments generally do not regulate these plans. The U.S. Department of Labor does (IDOI: Resolving Health Care Insurance Disputes).

Common mistakes to avoid

• Assuming the denial is final. Network status errors and protected emergency claims are often fixable.
• Paying a surprise bill before you check your rights. If the care was an emergency or at an in-network facility, ask questions first.
• Not saving the directory page. If you checked the plan’s directory before your visit, keep proof.
• Mixing up IDR and appeals. IDR is between your provider and your plan. Your own appeal is a separate step with its own deadline.
• Waiting too long. File before the deadline, even while you wait on a call back.

Where to get help

• No Surprises Help Desk: 1-800-985-3059 (CMS: Medical bill rights)
• Kentucky Department of Insurance, Division of Consumer Protection: (800) 595-6053, Option 1 (in Kentucky), or (502) 564-6034 (KY DOI)
• Indiana Department of Insurance Consumer Services: (800) 622-4461 or (317) 232-2395 (IDOI Consumer Services)
• Self-funded plans in Indiana: U.S. Department of Labor, Chicago office (312) 353-0900 for northern Indiana or Cincinnati office (859) 578-4680 for southern Indiana (IDOI)