Ambulance bills

Ambulance bills are among the largest surprise bills, and the rules differ sharply between air and ground. First find out which kind of ambulance you used. Then find out whether the bill comes from a denied claim, a low payment, or a balance the plan did not pay.

What this means

Air ambulance (helicopter or airplane). If you have employer coverage (including the Federal Employees Health Benefits program), Marketplace coverage or other individual coverage, an out-of-network air ambulance provider may not bill you more than in-network cost sharing. The protection also covers grandfathered plans. Short-term plans, health care sharing ministries and fixed indemnity plans are not covered.

Ground ambulance. Ground ambulance services are not covered by the No Surprises Act. That means the Act’s bar on extra bills does not apply to ground ambulance. Your protections come from three places:

• Your plan’s claims and appeal rights. A denied or underpaid ambulance claim can be appealed like any other claim.
• State law. Some states limit ground ambulance bills for insured plans. The Colorado page lists a state law that limits you to in-network cost sharing for private ground and air ambulance services. The Texas page lists a state law that bans surprise ground ambulance bills for plans whose cards show “TDI” or “DOI” and for state employee and teacher plans. These laws do not reach self-funded employer plans. See Colorado and Texas. Other states may have rules; check your state page.
• Negotiation with the ambulance company.

What to do

1. Find out which kind of ambulance it was. The bill or the explanation of benefits shows. (You.)
2. For air ambulance, use the surprise bills guide. Ask the plan to reprocess at in-network cost sharing and tell the provider in writing. Complain if the bill continues: call the No Surprises Help Desk at 1-800-985-3059 or use the online complaint form on the Centers for Medicare & Medicaid Services website. We could not confirm the Help Desk’s hours, so ask when you call. (You.)
3. For a ground ambulance denial, read the reason. Common reasons are out of network, “not medically necessary” or no prior approval. The denial notice must name the specific reason and the plan provision. (You.)
4. Ask for the ambulance company’s records and its itemized charges. You have a federal right under the health privacy law (the Health Insurance Portability and Accountability Act) to a provider’s billing records. This site found no general federal right to an itemized bill, so ask for the itemized charges as a request. The trip record shows why the ambulance was called and what condition you were in. (You.)
5. Appeal the denial in writing. Describe the emergency in plain words: what happened, how you felt, why you could not safely travel another way. Attach the trip record and any emergency room records. Employer and non-grandfathered individual plans must allow at least 180 days after you receive the denial to appeal. Check the date on your notice, which controls. (You.)
6. If the denial is about prior approval, point out that a plan cannot deny a claim for lack of prior approval where getting approval was impossible or could seriously jeopardize life or health. This is a rule of the federal claims procedure for employer plans. (You.)
7. If the plan paid but you still owe a balance, ask for the plan’s allowed amount in writing, then ask the ambulance company to reduce the balance. The bill negotiation offer letter and the guide on negotiating a medical bill help. Ask for a hold on collections while you do. (You.)

What the plan may say, and what to say back

“The ambulance was not medically necessary.” Ask for the specific plan provision and for the clinical standard it used. Send the trip record and emergency room records that show your condition. Ask the plan to explain how it applied the standard to your circumstances.

“The ambulance company is out of network.” For air ambulance, the Act applies. For ground ambulance, ask whether your state law or plan terms give in-network treatment in an emergency. Ask the plan to put its answer in writing.

The rule

An out-of-network air ambulance provider may not bill the patient more than in-network cost sharing; ground ambulance services are not covered by the No Surprises Act. 45 Code of Federal Regulations (CFR) 149.440

Watch for

• Medicare ambulance claims. If Original Medicare denied your ambulance claim, follow the Medicare appeal levels on your Medicare Summary Notice. See the Original Medicare appeals page.
• Emergency cost sharing. The federal emergency rule covers emergency department services. We could not confirm that it covers ground ambulance.
• Collections. Do not ignore collection letters. Respond in writing and see medical debt in collections.
• Self-funded plans. Complaints go to the federal Department of Labor, not the state.

What next

• Surprise bills and the No Surprises Act: the protected cases in full.
• Negotiate a medical bill: working with a provider on what you owe.
• The bill while you appeal: how to protect yourself during an appeal.
• Original Medicare appeals: if Medicare denied the claim.