You can often see a plan's members out of network while a dispute runs, within limits. Non-contracted providers must accept Original Medicare amounts from Medicare Advantage members. Medicaid plans must cover out of network when their networks cannot provide a service, at no added cost to the member. Federal surprise-billing rules restrict balance billing in emergency and in-network facility settings.
A dispute with a plan is measured in weeks and months. Your patients' needs are measured in days. While you work toward a contract, you can often keep seeing a plan's members out of network, but the rules differ sharply by program, and getting them wrong creates refund obligations or worse. What follows is a map of the main limits as of October 2026. It is general information, not legal or billing advice for your situation.
Can you see Medicare Advantage members without a contract?
It depends on the plan type and the member's benefits, but the payment rule for non-contracted providers is fixed. Under 42 CFR 422.214(a)(1), a provider without a contract establishing payment amounts for an enrollee of an MA coordinated care plan, MSA plan or private fee-for-service plan "must accept, as payment in full, the amounts that the provider could collect if the beneficiary were enrolled in original Medicare." In practice, you are paid as if under Original Medicare, and you cannot bill the member beyond that.
When a coordinated care plan's network cannot meet a member's needs, the plan must "arrange for and cover any medically necessary covered benefit outside of the plan provider network, but at in-network cost sharing, when an in-network provider or benefit is unavailable or inadequate" (42 CFR 422.112(a)(1)(iii)). That is the opening for a per-patient agreement or authorization. Private fee-for-service plans work differently and, notably, may not refuse to contract on the basis of network size (422.205(b)(1)); see private fee-for-service plans and the network-size exception.
What about Medicaid managed care members?
If a Medicaid plan's network "is unable to provide necessary services, covered under the contract, to a particular enrollee," the plan "must adequately and timely cover these services out of network for the enrollee, for as long as" its network cannot provide them (42 CFR 438.206(b)(4)). It must require the out-of-network provider to coordinate payment with it and ensure the enrollee's cost is "no greater than it would be if the services were furnished within the network" (438.206(b)(5)).
Two practical points follow. First, coordinate before you treat: get the authorization or single-case agreement in writing. Second, Medicaid managed care network providers must be enrolled with the state (42 CFR 438.602(b)), and participating Medicaid providers must accept Medicaid payment plus allowed cost-sharing as payment in full (42 CFR 447.15). Do not plan to bill Medicaid members privately without checking your state's rules.
What can you charge commercially insured patients?
For commercial plans, out-of-network benefits depend on the member's plan design. Federal surprise-billing rules restrict balance billing in specific situations:
- Emergency services at a hospital emergency department or independent freestanding emergency department (45 CFR 149.410).
- Non-emergency services by a nonparticipating provider at a participating facility (45 CFR 149.420). Certain ancillary services, including emergency medicine, anesthesiology, pathology, radiology, neonatology, and diagnostic services, are always protected; others can be billed only with the notice and consent the rule describes.
- Directory reliance. If a member relied on a plan directory or response saying you were in network, the plan may not charge more than in-network cost-sharing (42 U.S.C. 300gg-115(b)), and a provider who billed and collected more must refund the excess with interest (42 U.S.C. 300gg-139(b)).
Outside those situations, a clinician seeing a patient in a private office generally bills under the member's out-of-network benefit and any state law that applies. Many states have their own balance billing statutes; check yours on the network access laws index and with your billing advisor.
Are self-pay patients an option?
For uninsured patients, and insured patients who choose not to use their coverage, you must give a good faith estimate of expected charges when they schedule or ask (45 CFR 149.610). The deadline depends on timing: when a service is scheduled at least 3 business days ahead, within 1 business day of scheduling; when scheduled at least 10 business days ahead, within 3 business days; when the patient asks, within 3 business days of the request.
Is there a way to be paid in network before the contract is final?
In some states, yes. Texas requires managed care plans to treat a physician who joins an established medical group with a current contract "as if the physician were a participating provider" for payment purposes once the physician submits the credentialing information the plan requires (Tex. Ins. Code 1452.104), with subchapters extending similar treatment to certain podiatrists and therapeutic optometrists. If credentialing then fails, the plan may recover the difference between in-network and out-of-network payments (1452.106). Other states have provisional credentialing rules; see provisional credentialing laws.
How do you protect the dispute while billing out of network?
- Keep a log of every member you saw, the plan, the date, and whether the plan authorized care. Patterns of members seeking you out are evidence of an access gap, provided you use them without identifying patients unless they authorize it.
- Request single-case agreements for ongoing patients, especially where the plan cannot point to an in-network alternative within a reasonable distance or wait.
- Do not misrepresent network status. Tell patients plainly that you are out of network and what that means for their costs.
- Watch reconsideration and reapply dates so interim billing never replaces the main effort.
How do we help?
We prepare single-case agreement requests and the supporting access evidence for each patient, at $350 per agreement, and keep the main dispute moving. You sign and send every request, and you or your billing service submit the claims; we do not do billing. Claims appeals belong with White Glove Medical Billing, a separate company. We do not give legal advice. Prices are on our pricing page. Legal questions, such as what a contract term means or whether to pursue a hearing, belong with a healthcare attorney.
Common questions
- How much can I collect from a Medicare Advantage member if I am not in network?
- Under 42 CFR 422.214, a non-contracted provider must accept as payment in full what it could collect if the member were in Original Medicare. Whether the member has out-of-network benefits depends on the plan type.
- Does a Medicaid plan have to pay me if its network has no one available?
- If its network cannot provide a covered service to a particular enrollee, it must cover the service out of network for as long as the gap lasts, coordinate payment with you, and keep the enrollee's cost no higher than in network (42 CFR 438.206(b)(4) and (5)).
- Can I balance bill a commercially insured patient?
- Not for emergency services or for many services at in-network facilities under the No Surprises Act rules, and not above in-network cost-sharing if the patient relied on a directory listing you as in network. Other situations depend on the plan and state law.
Turned Down by a Payer?
We research the rejection and prepare the reconsideration request, the evidence and the letters for you to sign and send, then track every deadline.