Your Rights and Protection Against Surprise Billing Act

Beginning January 1,2020, Colorado state law protects you from Surprise Billing,” also known as Balance Billing.” Also beginning January 1, 2022, Federal law protects you from “surprise billing” and “balance billing.”


When you get emergency care or get treated by an out-of-network provider at an in-network hospital

or ambulatory surgical center, you are protected from surprise billing or balance billing.


When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or must pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network

providers may be permitted to bill you for the difference between what your plan agreed to pay, and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit. “Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.


Emergency Services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. You’re never required to give up your protection from balance billing. You also are not required to get care out-of-network. You can choose a provider or facility in your plan’s network.

Non-Emergency services at an in-network facility by an out-of-network provider. (Colorado state law)

The facility or agency must tell you if you are at an out-of-network location or at an in-network location that is using out-of-network providers. They must also tell you what types of services that you will be using may be provided by an out-of-network provider.

You have the right (Colorado Law)

To request that in-network providers perform all covered medical services. However, you may have to receive medical services from an out-of-network provider if an in-network provider is not available. In this case, the most you can be billed for covered services is your in-network cost-sharing amount which are copayments, deductibles, and/or coinsurance. These providers cannot balance bill you for additional costs.


• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

• Your health plan generally must:

- Cover emergency services without requiring you to get approval for services 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 and show that amount in your explanation of benefits.

- Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

- Your provider, facility, hospital, or agency must refund any amount you overpay within 60 days of being notified. (Colorado State Law)

If you believe you’ve been wrongly billed, you may contact Premier Eye Surgery Center (PESC) billing department, Colorado Division of Insurance, or Federal Agency.

• PESC billing department contact: 303.801.3393

• Colorado Division of Insurance contact: 303.894.7490 or 1.800.930.3745

The Colorado law only applies if you have “CO-DOI” on your health insurance ID card and you are receiving care and services provided at a regulated facility in the state of Colorado.

• Federal Agency contact: 1.800.985.3059

• Website Federal Agency:

Federal law applies to consumers enrolled in group health plans, group or individual health insurance coverage, and Federal Employees Health Benefits plans.


PESC is a participating provider in many health plans and networks. PESC will provide you with a list of plans in which we participate upon request. Some health plans may use smaller networks for certain products and services they offer, so it is important to check whether PESC participates in the specific plan you are covered by.

PESC would like you to understand that the physician services you receive at our facility are not included in the surgery center charges. Physicians who provide services at PESC may be independent physicians or they may be employed by PESC. Independent physicians bill separately for the services they provide and may or may not participate in the same health plans as PESC. You should check with the physician arranging your surgical services to determine which plans he or she may participate in.