STANDARD SERVICES PRICE GUIDE

When you receive emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing. These protections ensure that you are only billed what you would normally pay in-network—such as your plan’s copay, coinsurance, or deductible—and not the full out-of-network cost.

When you visit a doctor or health care facility, you usually pay out-of-pocket costs that your insurance plan allows. But if you are treated by a provider who is not in your plan’s network, they may bill you for more than your plan covers. This is called balance billing.

Balance billing is most common when:

• You receive emergency care and cannot choose your providers
   
• You visit an in-network facility but are unknowingly treated by an out-of-network specialist
   

These unexpected bills are called surprise medical bills, and they can be very costly.

1. Emergency Services

If you have a medical emergency and receive care from an out-of-network provider or facility, you can’t be charged more than your in-network rate.
This includes care received after you are stabilized, unless:

• You give written consent, and
• You agree to give up your protection from balance billing.

2. Certain Services at In-Network Hospitals or Ambulatory Surgical Centers

You are also protected if you receive care at an in-network hospital or surgical center but are treated by an out-of-network provider.
This applies to services like:

• Emergency medicine
• Anesthesia
• Radiology
• Pathology
• Neonatology
• Laboratory services
• Assistant surgeons
• Hospitalists and intensivists
   

These providers cannot balance bill you, and they are not allowed to ask you to waive your protections.

If you receive care outside of these categories (like physical therapy or specialty consultations) at an in-network facility, the provider may balance bill you only if:

• They notify you in advance, and
• You agree in writing to be billed out-of-network.

When you choose a provider or facility within your health plan’s network, you’re protected from unexpected charges. Even when balance billing isn’t allowed, you’re still entitled to the following protections:

• You’ll only be responsible for your usual cost-sharing—such as copayments, coinsurance, and deductibles—just as you would with in-network care.
• Your health plan will pay the rest directly to out-of-network providers or facilities.
   

• Cover emergency services without requiring prior authorization.
• Pay for emergency care from out-of-network providers.
• Base your cost-sharing (the portion you owe) on in-network rates and list these amounts in your Explanation of Benefits (EOB).
• Apply your payments toward your in-network deductible and out-of-pocket maximum, even when the care is out-of-network in an emergency or protected situation.

• Call the federal No Surprises Help Desk at 1-800-985-3059
• Visit: www.cms.gov/nosurprises/consumers

• Visit: www.cms.gov/nosurprises/consumers
• Email: FederalPPDRQuestions@cms.hhs.gov
• Or call: 1-800-985-3059

This information complies with CMS Price Transparency regulations.  This information is a base set of charges which might be utilized for patients receiving services at Mountain View Hospital. The exact charges for individual patients could be slightly different, since treatment is individualized by patient to best treat the diagnosis, presenting signs and symptoms

If you have any questions about these documents, please Contact Us.