Insurances

California and Federal Law Protect Patients from Surprise Medical Bills

When getting emergency care or treatment from an out-of-network provider at an in-network hospital, ambulatory surgical center or laboratory, California Law and the federal No Surprises Act protect you from balance billing and surprise billing.  In most cases, providers cannot bill patients with insurance more than their in-network cost sharing unless the patient has consented.

At scheduling, all UCR Health patients who are uninsured, self-pay, or out-of-network are eligible for a good faith estimate of the cost of items or services expected to be furnished.

Understanding balance billing and surprise billing

When you see a doctor or other health care provider, you may have certain out-of-pocket costs, including a copayment, coinsurance or deductible. You may have other costs or need to pay the entire bill if you see a provider or visit a facility that isn’t in your health plan’s network.

Balance billing occurs when out-of-network providers or facilities bill you for the difference between what your plan agreed to pay and the full amount they charge for a service. This payment might not count toward your annual out-of-pocket limit. Surprise billing is when you receive an unexpected balance bill.

Balance billing and surprise billing can happen when you can’t control who is involved in your care – such as when you need emergency services or schedule a visit at an in-network facility, like a hospital or laboratory, but unexpectedly receive treatment from an out-of-network provider.

You are protected from these types of surprise balance billings. In many instances, out-of-network providers can’t balance bill you unless you provide written consent. There are no circumstances under which you are required to give up your protections from balance billing.

Protections when balance billing is prohibited

When balance billing is prohibited, such as when you have not consented in advance, you are responsible only for your share of the cost of the care you received.

• This may include the copayments, coinsurance and deductibles that you would pay with an in-network provider or facility.
• Your health plan will pay out-of-network providers and facilities directly, and you shouldn’t have to pay out of pocket for more than your share of the cost.

Your health plan generally must provide the following protections:

• Cover emergency services without requiring approval in advance (prior authorization)
• Cover emergency services by out-of-network providers
• Base what you owe the provider or facility (cost sharing) on what it would pay an in-network provider or facility
• Count the amount you pay for emergency or out-of-network services toward your deductible and out-of-pocket maximum

If you believe you were wrongly billed

If you believe you were wrongly billed for care you received from a UCR Health provider, please contact a UC Riverside Health customer service representative by:

• Calling 855-482-7411 during our business hours, Monday through Friday, 9 a.m. -6 m.
• Logging in to your MyChart account at: ucrhealth.org.

If you get a surprise bill for more than your in-network cost share, file a grievance/complaint with your health plan and include a copy of the bill. Your health plan will review your grievance and should tell the provider to stop billing you for amounts greater than your in-network cost share.

If you do not agree with your health plan’s response or they take more than 30 days to fix the problem, you can file a complaint with one of the health-plan-regulation agencies listed below:

• For plans regulated by the Department of Managed Health Care, go online to ca.gov or call 888-466-2219.
• For plans regulated by the California Department of Insurance, go online to ca.gov or call 800-927-4357.
• If you do not know the type of plan you have, please call the Department of Insurance Help Center at 800-927-4357.

For more information about your rights under federal law, visit cms.gov/nosurprises. 

Thank you for choosing UC Riverside Health and for the opportunity to care for you.