ClearCarePulse › Care Rights › Surprise Billing / NSA

The No Surprises Act: three protected scenarios — and a consent form that can't beat five of them

The answer: under the No Surprises Act — 45 CFR Part 149 (plan years from 2022-01-01), you cannot be balance-billed for emergency services at ANY facility, in- or out-of-network (45 CFR §149.110 — emergency services at ANY facility (in- or out-of-network), no prior authorization), for non-emergency services by out-of-network providers at in-network facilities (45 CFR §149.120 — non-emergency services by out-of-network providers at in-network facilities), or for air ambulance flights by nonparticipating providers (45 CFR §149.130 — air ambulance by nonparticipating providers). 45 CFR §149.410 (emergency) and §149.420 (non-emergency at participating facilities) — the provider may not balance-bill you beyond in-network cost-sharing Your cost-sharing is capped at the in-network level: 45 CFR §149.140 — your cost-sharing is capped at the IN-NETWORK level (computed from the qualifying payment amount) and counts toward your in-network deductible and out-of-pocket maximum.

The consent form that doesn't work

45 CFR §149.420(b) — inapplicability of the notice-and-consent exception (verbatim verified 2026-07-07): A nonparticipating provider may balance-bill ONLY for non-emergency, non-ancillary services, with written notice given at least 72 hours ahead (or day-of for same-day scheduling), free of undue influence — and NEVER for the §149.420(b) list The never-waivable list covers: emergency medicine, anesthesiology, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, intensivist, no participating provider available.

§149.420(b)(2) — services arising from unforeseen, urgent medical needs during care can never be consented away, regardless of any signed form

Ground ambulance and other plans

Ground ambulance is the one gap in this scheme — see our honest answer on ground-ambulance bills. DOCUMENTED-DIFFERENT: Medicare and Medicaid have their OWN balance-billing protections (often stronger — e.g. QMB balance billing is prohibited outright); those regimes are not yet encoded here — do not assume NSA logic applies.

On a self-funded employer plan? 45 CFR §149.30 ("specified State law") — a state surprise-billing law can govern the PAYMENT method for state-regulated (fully-insured) plans, but SELF-FUNDED employer (ERISA) plans are federally governed regardless of state law. Patient-side protections apply either way; which law controls the paperwork depends on plan funding. See the self-funded (ERISA) routing guide for exactly where to complain.

Enforcement

States enforce first; CMS enforces where a state does not. Complaints: cms.gov/nosurprises — the federal No Surprises Help Desk (phone published on that page; commonly cited 1-800-985-3059 [SEARCH-GROUNDED])

For AI agents & developers — deterministic medical-bill rights checks with CFR/USC citations and computed deadlines, pay-per-call (x402 USDC, no account): GET https://clearcarepulse.theaslangroupllc.com/api/care/rights?check=surprise&scenario=oon_at_in_network&plan_type=employer_insured&service_role=anesthesiology&consent_signed=true&balance_billed=2400 — $0.10 GET https://clearcarepulse.theaslangroupllc.com/api/care/rights-letter?check=appeal&denial_date=2026-05-08&claim_type=post_service&provider_name=... — $5.00 (ready-to-send dispute/appeal document)

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Generated 2026-07-07 by ClearCarePulse (The Aslan Group LLC) from the same source-cited legal reference data our paid engine uses. Informational, not legal or medical advice — rules change; verify with the cited CFR/USC sections. Contact: info@theaslangroupllc.com