Out-of-Network Billing Services

Out-of-network billing services

Out-of-network billing services bill payers you have no contract with, follow the claims to payment, and apply the No Surprises Act before any patient is billed.

We'll look at how your non-contracted claims are sorted and disputed today. No patient data needed.

Since January 1, 2022, the Act limits what an out-of-network provider can bill a patient for emergency care, non-emergency care at an in-network facility and air ambulance services, and gives providers a federal dispute process over the plan's payment. The job is sorting protected claims from ordinary ones, meeting the notice and estimate rules, and disputing low payments inside the windows.

This is part of getting the claim out clean. Buy it on its own or pair it with our other billing services, stage by stage.

Last reviewed October 21, 2026 by the Remitwright billing team. Editorial policy

What out-of-network billing covers

Each out-of-network claim classified: protected under the No Surprises Act, covered by a state surprise billing law, or an ordinary non-contracted claim paid under the plan's out-of-network benefit

Notice and consent handled only where the rules allow it, never for the ancillary services they exclude, such as anesthesiology or radiology at an in-network facility

Good faith estimates for uninsured and self-pay patients when care is scheduled or when the patient asks, kept on file against the final bill

Claims filed with the documentation that supports the charge, and the plan's initial payment or denial logged with its date, because the dispute clocks start there

Denials with CARC 242, the code for care from a provider outside the payer's network, checked against the patient's out-of-network benefit before anything moves to the patient

Plan payments compared with the qualifying payment amount information plans must disclose, with open negotiation and then federal independent dispute resolution started inside their windows on the ones worth contesting

Patient cost sharing on protected services billed at the in-network amount the plan states, with the disclosure notice posted and given as the rules require

What goes wrong when out-of-network billing is skipped

The protected claim billed like any other

An anesthesia group is out of network at an in-network hospital. The plan pays something and the office bills the patient the difference, as it did before 2022. The Act bans that balance bill, notice and consent is not available for anesthesiology, and the group has a complaint instead of a payment.

The negotiation window nobody counted

The plan's payment arrives low. The biller means to dispute it and sends an ordinary reconsideration letter instead. The 30-business-day open negotiation period was never started, the 4-business-day window to begin IDR never opened, and the only path left is the plan's own appeal process.

The estimate that was never written down

A self-pay patient schedules a procedure and nobody gives the written good faith estimate the rules require. The final bill is far above what the patient was told on the phone, and the practice has nothing on file to defend it.

How we run out-of-network billing

Sort

Every non-contracted claim is tagged protected, state-law or ordinary before it goes out, with the reason recorded.

Notify and estimate

Disclosure notices, notice and consent where the rules allow it, and good faith estimates for uninsured and self-pay patients, all dated and filed.

Bill and log

Claims sent with supporting documentation; the plan's initial payment or denial date logged when it arrives.

Negotiate and dispute

Open negotiation started on contested payments; IDR initiated inside the window when negotiation fails; the offer prepared with the supporting information the certified IDR entity needs.

Collect what is allowed

Patient statements for protected services limited to the in-network cost sharing the plan states; ordinary out-of-network balances billed under your written policy.

What you receive every week

Out-of-network claim log

Each claim's classification, plan payment, date received, negotiation and IDR status, and next deadline.

Dispute file

For each contested claim: the plan's payment, the qualifying payment amount information received, the offers made and the outcome.

Out-of-network report

Billed, paid by plans, in negotiation, in IDR, decided and patient-billed, by plan.

Worked example: one physician, two kinds of claim

A hypothetical urgent care is out of network with a regional plan. A patient on that plan comes in with a laceration. None of the Act's three protected situations applies to a scheduled-hours visit at a freestanding clinic, so the claim is ordinary out-of-network: the plan is billed, and the patient gets the balance under the clinic's written policy once the plan has paid. Separately, the clinic's physician covers shifts in an in-network hospital emergency department while out of network with that plan. Those claims are protected: the patient is billed only the in-network cost sharing, and the low payments go into open negotiation.

Questions about out-of-network billing

What does the No Surprises Act stop us from billing?

The balance between your charge and the plan's payment, in three situations: emergency services, non-emergency services by an out-of-network provider at an in-network facility, and out-of-network air ambulance services. There the patient pays in-network cost sharing and the dispute is with the plan, not the patient. The protections took effect on January 1, 2022.

Can the patient agree to be balance billed?

Sometimes. The rules allow a notice and consent process for some non-emergency out-of-network care, but not for specified ancillary services at an in-network facility, such as anesthesiology or radiology. We treat consent as the exception, documented and kept on file, never the default.

How does the federal dispute process work?

After the plan's initial payment or denial there is a 30-business-day open negotiation period. If that fails, either party has 4 business days to start the federal IDR process. Each side submits an offer with supporting information to a certified IDR entity, which picks one of the two offers, and payment follows within 30 calendar days. CMS has announced that the process moves to a new IDR Gateway in late 2026.

What is the qualifying payment amount?

The plan's median contracted rate for the service on January 31, 2019, indexed for inflation, as the Part II rules define it. For protected services the patient's cost sharing is calculated from it unless state law or an All-Payer Model Agreement applies, and plans must disclose it, so it is the first number we compare a payment against.

Do we have to give good faith estimates to every patient?

To uninsured and self-pay patients, when they schedule care or when they ask. A patient who receives a bill at least 400 dollars more than the estimate can start the patient-provider dispute process within 120 calendar days of receiving the bill. We produce the estimates from your fee schedule and keep each one with the account.

Does the Act apply to ordinary out-of-network claims where we simply have no contract?

Not outside the three protected situations. Those claims are paid under the plan's out-of-network benefit and the balance is yours to bill under your own written policy, subject to any state law that applies.

Will you tell us when staying out of network is costing us?

Yes. The out-of-network report shows what plans pay against your charges and how many claims end up in negotiation or IDR. If a contract would pay better, we say so. The decision is yours, and payer enrollment handles the paperwork if you join.

Can an outside biller handle our out-of-network claims while in-network claims stay in-house?

Yes. Out-of-network claims carry the notice-and-consent paperwork, the qualifying payment amount checks and the negotiation and IDR timelines, so splitting them off is common. The biller works them inside your system.