Which emergency services the No Surprises Act covers

Which emergency services does the No Surprises Act cover?

The Act covers the medical screening exam and the further exam and treatment needed to stabilize the patient, at a hospital emergency department or an independent freestanding emergency department. Services after stabilization are covered too, during the same visit, unless a notice and consent exception applies. The definition is in 45 CFR 149.110(c)(2).

The screening standard comes from EMTALA, section 1867 of the Social Security Act. EMTALA and billing explains what that law requires of the hospital. For an independent freestanding emergency department, the rule applies the standard as if section 1867 applied to it.

What counts as an emergency medical condition?

The test is a prudent layperson standard, not a diagnosis list. An emergency medical condition is one with acute symptoms of sufficient severity, including severe pain, that a prudent layperson with average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to place health in serious jeopardy, seriously impair bodily functions or cause serious dysfunction of an organ or part (149.110(c)(1)).

The same section bars a plan from limiting what counts as an emergency medical condition solely on the basis of diagnosis codes (149.110(b)(4)). It also requires coverage without any prior authorization determination, even when the services are out-of-network (149.110(b)(1)). That gives you two arguments when a plan denies an ED claim for a final diagnosis that looks minor or for a missing authorization.

Which facilities does it apply to?

The emergency protections apply to hospital emergency departments, hospital outpatient departments that provide emergency services, and independent freestanding emergency departments. 45 CFR 149.30 defines the last as a health care facility that is geographically separate and distinct and licensed separately from a hospital under state law, and that provides emergency services.

A walk-in urgent care center counts only if it meets that definition. CMS says in its key protections document that only urgent care centers licensed to provide emergency services, and geographically separate and distinct and licensed separately from a hospital, are considered independent freestanding emergency departments. Confirm your state license before you rely on the emergency protections in a payer dispute. The freestanding ER guide covers the billing side.

What can the patient be billed?

A nonparticipating emergency facility or provider must not bill the patient more than the in-network cost-sharing amount for emergency services (149.410(a)). That covers the facility and each nonparticipating provider who treats the patient during the visit, including the emergency physician.

The plan must calculate cost sharing as if the total amount charged were equal to the recognized amount, and count the patient's payments toward in-network deductibles and out-of-pocket maximums (149.110(b)(3)(ii) to (v)). The rest of the payment is between the plan and the provider, through open negotiation and, if that fails, federal IDR. Start with the No Surprises Act hub for that process.

How fast must the plan pay an emergency claim?

The plan has 30 calendar days to decide coverage and send an initial payment or a notice of denial. The 30 days run from the date the plan receives the information needed to decide the claim (149.110(b)(3)(iv)(A)). Then the plan must pay the balance up to the out-of-network rate, less the initial payment, directly to the provider or facility.

The date matters because the open negotiation clock starts from the initial payment or denial, as the deadline calculator shows. Log that date on every emergency claim when the remittance posts.

What does the Act not cover?

• Medicare, including Medicare Advantage, and Medicaid: CMS lists them as outside the protections, along with CHIP, TRICARE, VA and IHS coverage.
• Ground ambulance services: the 2026 IDR operations rule's preamble says the surprise billing protections do not apply to ground ambulance services.
• Care outside the plan types the Act reaches: short-term plans and several other coverage types are outside it. Check the member's plan type on the eligibility response.
• Urgent care that is not licensed as described above: it does not carry the emergency protections.
• Services where state law governs: some states have their own surprise billing laws. See state surprise billing laws for how those interact with the federal rule.

How should an ER group check each claim?

Example: a commercial plan member arrives at an independent freestanding ER with chest pain, receives a screening exam, an ECG and treatment, and is transferred. All of that is emergency services. The physician's professional claim and the facility claim each carry the patient's in-network cost sharing only, with no balance bill.

How we handle it

We run eligibility assessment, open negotiation and deadline management for out-of-network emergency claims, as part of our out-of-network billing and IDR service. That work supports emergency medicine billing groups from the first remittance to the final payment. Book a call to review how your claims are classified. More posts are on the blog.