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Part of: What was denied

Denial reason · Coverage

Out of network

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The plan says your provider or facility is not in its network. Federal law protects you in emergencies and in several hospital situations, so check which situation you are in before you pay.

On this page 7
Who has to act first
You. You work out which situation applies (an emergency, an out-of-network clinician at an in-network facility, a wrong directory listing, or a provider you chose) and ask the plan to reprocess the claim. Your doctor helps if you need a network exception.
Can it go to external review?
Sometimes. It depends on what the decision turns on. A denial can qualify when it turns on medical judgment, for example a plan that covers out-of-network care when a service cannot effectively be provided in network, or on whether No Surprises Act protections apply. A plain rule that your plan has no out-of-network benefit may not qualify. Check the notice.

Wording you may see on your letter

  • Out-of-network provider
  • Services received from a non-participating provider
  • The provider is not in your plan's network
  • Out-of-network benefits are not covered under your plan

What it means

The plan says the provider or facility that treated you does not have a contract with it. Plans often pay less for out-of-network care, and some pay nothing. Federal law limits what you can be charged in some situations, so do not assume the denial is right.

Who has to act first

You, usually. Start by finding which situation you are in: an emergency, a clinician you did not choose at an in-network hospital or surgical center, a provider the plan’s directory listed as in network, a provider who left the network during your treatment, or a provider you chose knowing they were out of network. The arguments below depend on that.

Ask the plan in writing to reprocess the claim. Before you pay a balance bill, ask the billing office in writing to confirm the amount and whether it will pause collections while you dispute it. It is not required to for an insured patient, so get any pause in writing. An unpaid bill can go to collections, so ask before you withhold any payment. If the No Surprises Act applies, you may owe only in-network cost sharing.

Your appeal deadline is at least 180 days after you receive the denial for a job-based plan or a non-grandfathered individual plan. Medicare, Medicaid and other public coverage have different deadlines. Check the date on your notice, which controls.

Arguments that work

  • Emergency care. A plan that covers emergency department care must cover emergency services without prior authorization, in or out of network, at no more than in-network cost sharing, and count that cost toward your in-network deductible and out-of-pocket maximum.
  • An out-of-network clinician at an in-network facility. The clinician may not bill you more than in-network cost sharing unless you signed a valid notice-and-consent waiver. A waiver can never be used for emergency medicine, anesthesiology, pathology, radiology, neonatology, assistant surgeons, hospitalists, intensivists, diagnostic services, or when no in-network provider was available at the facility.
  • Air ambulance is protected the same way. Ground ambulance is not covered by these rules.
  • A wrong directory listing. If you relied on directory information that said the provider was in network and it was wrong, the plan may not charge more than in-network cost sharing.
  • A provider who left the network. A “continuing care patient” (with a serious and complex condition, inpatient care, scheduled non-elective surgery, pregnancy or terminal illness) may elect to keep in-network terms with that provider for up to 90 days.
  • No suitable in-network provider. The federal external review rule gives, as an example of a reviewable denial, a plan that covers out-of-network care when a service cannot effectively be provided in network. Patient groups suggest showing that the provider is essential or that in-network waits are unreasonable.

These rules do not reach short-term plans, health care sharing ministries or fixed indemnity plans.

Evidence to gather

  • The denial notice and the Explanation of Benefits (EOB) (you).
  • A dated printout of the plan’s provider directory (you).
  • Your call notes with names and reference numbers (you).
  • Any consent form you signed (the facility).
  • An itemized bill showing who billed you for what (the billing office).
  • A list of in-network providers you tried, with waiting times (you).
  • A letter from your doctor on why this provider is needed (your doctor).
  • For an emergency: the record of your symptoms on arrival (the hospital).

What to send

Send a letter that says which situation applies, asks the plan to reprocess the claim at in-network cost sharing, and attaches the evidence. If you think the plan or provider broke the No Surprises Act, you can also complain to the No Surprises Help Desk at 1-800-985-3059.

When this is not worth an appeal

If you chose an out-of-network provider for care that was not an emergency, and your plan has no out-of-network benefit, an appeal can only ask the plan to apply its own terms. Ask instead whether the plan will grant a network exception, ask the provider for a self-pay price, and ask about hospital financial assistance.

Sources

Official and primary sources used on this page. Checked 2026-11-12.

  1. 45 CFR 149.110, emergency services — Electronic Code of Federal Regulations
  2. 45 CFR 149.420, out-of-network providers at in-network facilities — Electronic Code of Federal Regulations
  3. 42 U.S.C. 300gg-115, provider directory protections — Government Publishing Office
  4. 42 U.S.C. 300gg-113, continuity of care — Government Publishing Office
  5. CMS, Know your rights when using insurance (No Surprises Act) — Centers for Medicare and Medicaid Services
  6. 29 CFR 2590.715-2719, external review (examples of out-of-network denials) — Electronic Code of Federal Regulations

What next

Letters and scripts

  • Letter or script

    Appeal: out of network because no in-network option exists

    Asks your plan to cover out-of-network care at the in-network level because no in-network provider could give the care in time, or at all.

  • Letter or script

    Out-of-network necessity letter (for your clinician)

    A letter in your clinician's voice explaining why in-network care cannot meet the patient's needs, so the plan should cover an out-of-network provider. Every clinical and network statement is a blank for the clinician to complete.

  • Letter or script

    Appeal: emergency care denied

    Asks your plan to cover an emergency visit using the prudent layperson standard, judged on your symptoms at the time rather than the final diagnosis.

  • Letter or script

    No Surprises Act complaint

    Tell the federal government that you were billed more than the No Surprises Act allows, using the No Surprises Help Desk or the online complaint form.

  • Letter or script

    Ask the provider to hold the bill

    Ask a provider in writing to pause collection, interest and late fees on a bill while your insurance appeal is decided.

Tools

  • Tool

    Network exception builder

    Build a request to cover out-of-network care at in-network cost when the network cannot provide what you need.

  • Tool

    Surprise bill checker

    See whether the federal No Surprises Act may protect you from an out-of-network bill, with three plain steps, a phone script and two letters.

  • Tool

    Bill and statement reconciler

    Put your bill next to your Explanation of Benefits and see the mismatches to question.

  • Tool

    Denial reason finder

    Match the wording on your letter to a denial reason, see who must act first, and open the right playbook.

Checklists

  • Checklist

    Surprise bill response

    How to check whether the No Surprises Act protects you from an unexpected out-of-network bill, who to ask to fix it, and where to complain.

Related guides

  • Guide

    Out-of-network denials and network gap exceptions

    What to do when your plan denies or underpays care because the provider is out of network. Learn about network gap exceptions, continuity of care and the cases federal law protects.

  • Guide

    Out-of-network underpayment

    Your plan paid an out-of-network claim but far less than the provider charged. Learn how plans set the allowed amount and how to use price benchmarks in a dispute.

  • Guide

    Emergency room claim denied

    What to do when your plan denies or reduces an emergency room claim. Learn the prudent layperson standard and why a plan cannot require prior approval for emergency care.

  • Guide

    Surprise bills and the No Surprises Act

    Who the federal No Surprises Act protects, which out-of-network bills it bars, which it does not, and how to complain to the No Surprises Help Desk.

  • Guide

    Ambulance bills

    Air ambulance bills are covered by the federal No Surprises Act. Ground ambulance bills are not. Here is what to do about an ambulance bill or a denied ambulance claim.

  • Guide

    The bill while you appeal

    Appeals take months and the bill keeps coming. Ask the provider for a hold in writing, check the bill against your Explanation of Benefits, and do not pay what your plan may still owe.

  • Guide

    Keeping treatment going during an appeal

    When a plan has approved ongoing care and then cuts it short, the federal rules treat that as a denial with extra protections. Learn what to ask for so care does not stop while you appeal.

Denial reasons

  • Denial reason

    Not a covered benefit

    The plan says your policy does not cover this service. Read the exact exclusion, check whether the service really falls inside it, and check whether a law requires the plan to cover it anyway.

  • Denial reason

    Coding or billing error

    The claim itself has a wrong code, a wrong detail or a missing item. Your provider's billing office usually has to correct it and send it again. You help by asking for the codes, checking them against your records and following up.

Sources last checked . Found a mistake? Report it.