Balance Billing Laws in Pennsylvania
Your medical billing rights and protections in Pennsylvania.
Pennsylvania enacted the Fair Contracting for Health Care Practitioners Act (Act 90 of 2016) and subsequent surprise billing protections through Act 23 of 2021, which prohibit balance billing for emergency services and non-emergency services at in-network facilities without adequate notice. The laws establish consumer protections and a dispute resolution process for billing disagreements.
Key Protections in Pennsylvania
Emergency services: Balance billing prohibited for emergency care under Pennsylvania law; cost-sharing limited to in-network amounts
Non-emergency care at in-network facilities: Patients protected from balance billing when they had no meaningful choice of out-of-network provider
Dispute resolution: Pennsylvania Insurance Department oversees dispute resolution between providers and insurers
Disclosure: Out-of-network providers must provide advance notice and cost estimates before non-emergency services
Filing Information
Within 2 years of the date of service for state-level complaints
Additional Notes
Pennsylvania consumers can file complaints with the state Insurance Department or use the federal complaint process. Self-funded employer plans fall under federal No Surprises Act jurisdiction.
How to File a Complaint in Pennsylvania
Gather Your Documentation
Collect your itemized medical bill, Explanation of Benefits (EOB) from your insurer, any prior authorization documents, and written communications with the provider or insurance company.
File with the State Regulator
Submit your complaint to the Pennsylvania Insurance Department. Include all supporting documents and a clear description of the billing dispute.
File complaint with Pennsylvania Insurance DepartmentFile with CMS if Federal Protections Apply
If your dispute involves the No Surprises Act (emergency care or out-of-network providers at in-network facilities), you can also file directly with the Centers for Medicare & Medicaid Services.
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