Air Ambulance Billing Under the No Surprises Act

Does the No Surprises Act cover air ambulance services?

Yes. Under 45 CFR 149.30, an air ambulance service is medical transport by a rotary wing (helicopter) or fixed wing (airplane) air ambulance, as 42 CFR 414.605 defines those terms. The federal protections apply when a health plan covers air ambulance benefits and a nonparticipating provider flies the patient.

Balance billing means a provider bills the patient for the gap between its charge and what the plan pays. Under 45 CFR 149.130(a), any group health plan or issuer that "provides or covers any benefits for air ambulance services" must cover transports by nonparticipating providers under the rules in paragraph (b). Section 149.130(c) makes this apply to plan years, and individual-market policy years, beginning on or after January 1, 2022.

What does the balance billing ban require of the air ambulance provider?

A nonparticipating air ambulance provider must not bill the patient, or hold the patient liable, for more than the in-network cost-sharing amount. That is the rule in 45 CFR 149.440(a), and it covers air ambulance services furnished in plan years beginning on or after January 1, 2022.

The ban sets what the patient owes. It does not set what the plan owes you. Under 45 CFR 149.130(b)(4)(ii), the plan pays the provider directly the amount by which the out-of-network rate exceeds the patient's cost-sharing amount, less any initial payment already made.

The out-of-network rate comes from one of three places: an agreement between you and the plan, a certified IDR entity decision, or a specified State law or All-Payer Model Agreement. Any balance after cost sharing is a dispute with the plan, not a bill to the patient.

How is patient cost sharing set for air ambulance transport?

The patient's cost sharing is calculated as if the total charge were the lesser of the qualifying payment amount (QPA) or the billed amount. That is the rule in 45 CFR 149.130(b)(2). The QPA is the plan's median in-network rate, indexed, for the same service in the same region.

Under 45 CFR 149.130(b)(1), the cost-sharing requirements must match what would apply with a participating air ambulance provider. Under 149.130(b)(3), what the patient pays counts toward the in-network deductible and in-network out-of-pocket maximum.

How is the QPA calculated for air ambulance services?

The plan uses the same median-contracted-rate method as for other services, with four air ambulance adjustments in 45 CFR 149.140. The full method is on our qualifying payment amount page; this section covers only what differs for air transport.

• Region. Under 45 CFR 149.140(a)(7)(ii), the region is one for all metropolitan statistical areas in the State and one for the rest of the State, set by the point of pick-up. If the plan lacks enough data, the region widens to the Census division. 42 CFR 414.605 defines the point of pick-up as where the patient is placed on board the ambulance.
• Specialty. Under 45 CFR 149.140(a)(12), all providers of air ambulance services count as a single provider specialty.
• Mileage. Section 149.140 requires a separate median contracted rate for the air mileage service codes A0435 and A0436. The plan indexes that rate, then multiplies it by the loaded miles. Loaded miles are statute miles (not nautical miles) that the patient is transported in the vehicle.
• Disclosure. When cost sharing is based on the QPA or the billed amount, the plan must send the QPA in writing with each initial payment or notice of denial (45 CFR 149.140).

How quickly must the plan pay an air ambulance claim?

The plan has 30 calendar days to decide the claim and send an initial payment or a denial. Under 45 CFR 149.130(b)(4)(i), that clock starts when the plan receives the information it needs to decide the claim, counted from the bill the provider transmits.

After the initial payment or denial, the dispute path follows the standard federal timeline. Open negotiation can start within 30 business days of receiving the initial payment or denial, and runs 30 business days. If it fails, either side can start federal IDR within 4 business days after it ends (45 CFR 149.510 and 149.140). Our federal IDR process guide covers each step.

Can air ambulance providers use federal IDR?

Yes. IDR is Independent Dispute Resolution: a certified IDR entity picks one of two final offers. Under 45 CFR 149.510(a), a nonparticipating provider of air ambulance services and a plan can use it after open negotiation ends without agreement.

A transport qualifies when it is covered by the 45 CFR 149.130 protections and the out-of-network rate is not set by an All-Payer Model Agreement or a specified State law (45 CFR 149.510(a)(2)(xi)). Section 149.520(b)(1) then says the plan and the entity follow the general rules in 45 CFR 149.510, except for the air ambulance considerations in 149.520(b)(2).

Payment follows the same clock as other IDR disputes. Under 45 CFR 149.510(c), the amount of the selected offer, less the initial payment and any cost sharing the patient paid or owes, is due within 30 calendar days of the entity's determination. If the selected offer is lower than those amounts combined, the provider repays the plan the difference within 30 calendar days.

How do air ambulance disputes differ from other IDR disputes?

The entity must still consider the QPA. What changes is the list of other circumstances it considers. Under 45 CFR 149.520(b)(2), the entity must consider information from either party on these six points.

The general IDR list in 45 CFR 149.510(c) also includes market share and, for facilities, teaching status, case mix and scope of services. The air ambulance list in 149.520(b)(2) does not.

Under 45 CFR 149.520(b)(3), the entity should not give weight to information that is not credible, does not relate to either party's offer, or is already accounted for by the QPA or other credible information.

Your offer must be stated as a dollar amount and as a percentage of the QPA (45 CFR 149.510(c)). The entity must not consider usual and customary charges or public payor rates, including Medicare, Medicaid, CHIP and TRICARE. Both limits come from 149.510 and carry over through 149.520(b)(1).

Batching works for air ambulance disputes too. Under 45 CFR 149.510(c), up to 50 items can be decided together when the same provider of air ambulance services billed them (the same NPI or TIN), the same plan or issuer pays, and they meet the similar-condition and timing criteria.

Certified IDR entities also report on air ambulance cases. Under 45 CFR 149.520(b)(4), within 30 business days of the close of each month, an entity reports counts of initiation notices and determinations, how often the payment exceeded the QPA, and case details. Case details include billing codes, the point of pick-up, both offers, which offer won, the rationale and the vehicle type.

What data must air ambulance providers report to HHS?

The statute requires it, but the detailed reporting rule is not in the federal regulations yet. CMS's September 2021 fact sheet says the No Surprises Act requires providers of air ambulance services to submit data to HHS on transportation and medical costs, bases and aircraft, the number and nature of transports, payer data and claims denials. It says plans and issuers must report claims data.

The Departments proposed the rule that would set the details: "Requirements Related to Air Ambulance Services, Agent and Broker Disclosures, and Provider Enforcement," published September 16, 2021 at 86 FR 51730 (docket CMS-9907-P). CMS describes the proposal as requiring plans, issuers and air ambulance providers to submit data for each air ambulance claim and transport for the two years covered by the statute's reporting requirement.

Is the rule final? No final rule has been published. The October 2026 eCFR version of 45 CFR Part 149 has no section on air ambulance data reporting. A Federal Register search of docket CMS-9907 returns only the 2021 proposed rule. Treat the proposal as a proposal until the Departments publish a final rule.

CMS's fact sheet also describes civil money penalties. It says section 106(e) of the Act sets penalties of up to $10,000 on providers of air ambulance services for failing to submit the required data, and that the proposed rule would also codify the process for penalties of up to $10,000 per violation under section 2799B-4 of the PHS Act.

Does the No Surprises Act cover ground ambulance?

No. CMS's key protections toolkit states that "Ground ambulance services are not covered by the No Surprises Act," and adds that other remedies may be available. The federal IDR rule at 45 CFR 149.510 lists emergency services, certain non-emergency services and air ambulance services as its covered categories, and ground ambulance is not among them.

The Act did create the Ground Ambulance and Patient Billing (GAPB) Advisory Committee. CMS announced it on November 19, 2021, as a body that makes recommendations to the Secretaries of Health and Human Services, Labor and the Treasury on protecting consumers from exorbitant charges and balance billing for ground ambulance services. CMS describes its role as recommendations, not a billing ban.

Which states regulate air ambulance billing?

We do not list states on this page, because we have not confirmed a current list at an official source. The federal rule does say how state law fits in. If a specified State law or All-Payer Model Agreement sets the out-of-network rate, federal IDR does not apply (45 CFR 149.510(a)(2)(xi)), and the plan's payment timing follows that State law (45 CFR 149.130(b)(4)(ii)).

CMS also notes that specified state laws typically do not apply to self-funded group health plans unless the plan has opted in. Our state surprise billing laws page explains how state and federal rules sit together.

How we handle air ambulance disputes

We recover the revenue insurers underpaid you under the No Surprises Act. For air ambulance claims, that means checking the plan type and eligibility first, then working the claim through open negotiation and federal IDR, or the applicable state pathway where one governs, from first notice to final payment.

Our work on out-of-network reimbursement covers eligibility assessment, open negotiation, dispute submissions, deadline management, documentation validation and outcome tracking. We keep deadline tracking, required fees paid on time and jurisdiction-specific compliance checks under one set of controls. We measure IDR performance by decision win rate, award-to-offer ratio, reimbursement recovered and collections, using verified case-level data.

Our out-of-network billing and IDR service runs the whole workflow. For answers to other No Surprises Act questions, see the No Surprises Act FAQ. To have us review your open air ambulance claims, book a call.