The New Era of Balance Billing: A Small Practice Guide to the No Surprises Act (45 CFR § 149.30)

The No Surprises Act reshaped when and how small practices may bill patients for out-of-network care. While most attention goes to specific sections on emergency services and facility-based care, the real starting point for a clinic is 45 CFR 149.30, which defines the terms that decide whether those protections even apply.  If you cannot accurately answer whether your practice is acting as a “health care facility,” an “out-of-network emergency facility,” or an “out-of-network provider,” you cannot reliably decide when balance billing is prohibited.

Under 45 CFR Part 149 Subpart B, plans must treat many emergency and facility-based encounters as protected from balance billing, and providers and facilities are bound by parallel rules under Subpart E. These protections are no longer optional courtesy adjustments; they are statutory obligations backed by federal and state enforcement. For small practices that rely on out-of-network differentials to stay afloat, a misunderstanding of definitions can translate into forced refunds, complaints, and damaged payer relationships.

This guide uses 45 CFR 149.30 as the lens for building a small-practice balance-billing program: mapping how definitions apply to your setting, organizing services into a simple balance-billing matrix, and documenting decisions so you can defend them to payers and regulators.

For years, balance billing felt like a negotiation tool. If a visit was out of network, many small practices billed patients the difference between the charge and plan payment and then worked out adjustments one-on-one. The No Surprises Act, implemented at 45 CFR Part 149, changed that logic. In many common emergency and facility-based scenarios, balance billing is simply not allowed, and the patient’s financial obligation is tied to in-network cost sharing rather than the provider’s charge. 

Most small clinics are not reading the Federal Register in their spare time. Instead, they experience these changes through denials, recoupments, or new payer edits. When a plan cites 45 CFR 149.110, 149.120, or 149.130 and refuses to pay beyond the “recognized amount,” it is using the same definitional structure you should have used on the front end. 

By grounding daily decisions in 45 CFR 149.30’s definitions and then mapping them to operative balance-billing protections, a small practice can move away from case-by-case improvisation toward a stable playbook. That playbook reduces surprise bills, keeps staff from promising things they cannot legally do, and improves your negotiating position with payers because your documentation lines up with the regulations they must follow.

Understanding Legal Framework & Scope Under 45 CFR 149.30

45 CFR 149.30 is the definitional engine for No Surprises Act implementation in Part 149. It houses terms that affect whether particular encounters fall inside or outside federal balance-billing protections and related processes.  For small practices, several definitions are especially important:

• “Out-of-network provider” and “out-of-network emergency facility.” These definitions describe physicians and facilities that lack a contractual relationship with a plan or issuer for the item or service at issue.  The label determines whether No Surprises Act protections are triggered when you treat an enrollee.

• “Health care facility” in the context of non-emergency services. For non-emergency care, the definition of health care facility includes hospitals, hospital outpatient departments, critical access hospitals, and ambulatory surgical centers.  Services furnished by nonparticipating providers at these facilities may be covered by 45 CFR 149.120’s balance-billing protections if other conditions are met.

• “Cost sharing” and “recognized amount.” Cost sharing is defined to exclude balance billing by out-of-network providers, meaning that such balance billing cannot be treated as part of the patient’s deductible or out-of-pocket limit.  The “recognized amount” is defined elsewhere in Part 149 but is used throughout as the basis for determining patient liability and plan payment.

Once these definitions are understood, you can locate the main balance-billing rules:

• 45 CFR 149.110 prevents surprise medical bills for emergency services, tying patient liability to in-network cost sharing when certain criteria are met.

• 45 CFR 149.120 extends protections to non-emergency services performed by nonparticipating providers at certain participating health care facilities.

• 45 CFR 149.130 addresses air ambulance services.

Part 149 also establishes complaint processes and provider/facility obligations in Subpart E, such as specific prohibitions on balance billing in emergency situations and related disclosure duties.  States may overlay their own “specified state laws” that set alternative ways of determining payment amounts, but those incorporate the same concepts and often reference the same federal definitions. 

For a small clinic, mastering 45 CFR 149.30 means you can quickly tell which encounters are governed by federal balance-billing bans, which are governed by state law, and which remain traditional out-of-network scenarios. That clarity reduces billing friction, shortens payer disputes, and cuts the risk of a surprise-bill complaint turning into a regulatory file.

Even though these requirements arise from the No Surprises Act, they often surface in HIPAA and revenue-cycle reviews, where auditors examine the full patient financial experience. The following controls are designed for small practices and explicitly built around 45 CFR 149.30’s definitions and the balance-billing protections they support.

1. Build a “who are we?” NSA applicability map

   Explain the control: Start by mapping every location and service line to the definitions in 45 CFR 149.30. Determine whether you ever function as a “health care facility” for non-emergency services, whether you are connected to any “out-of-network emergency facilities,” and in which scenarios you act purely as a professional out-of-network provider.

   Evidence to retain: A one-page chart showing each practice location, its licensure status, whether it qualifies as a “health care facility” in the No Surprises Act sense, and examples of services furnished there. Attach citations to 45 CFR 149.30 and relevant state definitions.
   Low-cost method: Use an internal spreadsheet or shared document, updated annually by the practice manager and reviewed by your billing lead.

2. Create a red–yellow–green balance-billing matrix

   Explain the control: Using your applicability map, build a matrix that classifies encounters into three categories: red (balance billing prohibited, such as protected emergency services under 45 CFR 149.110), yellow (balance billing heavily restricted or subject to special processes, such as non-emergency services at certain facilities under 45 CFR 149.120), and green (traditional out-of-network billing permitted, subject to contract and state law).

   Evidence to retain: Save the matrix with version dates, and keep at least one example claim from each category where you can show how staff applied the matrix to billing decisions.

   Low-cost method: A color-coded PDF or laminated sheet at billing and scheduling workstations; no specialized software required.

3. Link payer contracts to the definitions

   Explain the control: For your top payers, crosswalk key contract terms (facility status, network status, payment methodologies) to 45 CFR 149.30’s definitions and the protections in 149.110–149.130. This helps staff see when the contract mirrors federal law and when it adds payer-specific limits on billing patients.

   Evidence to retain: A short contract summary for each major payer that references the relevant definitions and balance-billing sections, along with internal guidance on how to handle common disputed scenarios.

   Low-cost method: Use your existing contract summary or fee schedule binder and add one extra column for “NSA/45 CFR reference.”

4. Implement a balance-billing approval checkpoint

   Explain the control: Any proposed patient responsibility that exceeds plan cost sharing for an out-of-network encounter flagged as red or yellow in your matrix should go through a second-level review. A designated reviewer checks the encounter type against 45 CFR 149.30’s definitions, verifies whether 45 CFR 149.110, 149.120, or 149.130 apply, and confirms that no state surprise-billing law prohibits additional billing.

   Evidence to retain: A small log of “balance-billing approvals” showing date, patient identifier, service type, reviewer, and the CFR citation supporting the decision. This log can be critical if a patient later complains.

   Low-cost method: Add one extra step in your existing statement-approval workflow; the reviewer can be your billing manager or practice owner.

5. Tune patient communication scripts to the regulatory boundaries

   Explain the control: Update scheduling and financial counseling scripts to reflect 45 CFR 149.30’s terminology without overwhelming patients. Staff should be able to explain, in simple language, when a patient’s liability will be limited to in-network cost sharing because of federal protections, and when out-of-network charges may apply. Scripts should differ between emergency, facility-based, and office-based visits, in line with 45 CFR 149.110, 149.120, and 149.130.

   Evidence to retain: Current versions of scripts, quick-reference cards used at the front desk, and brief training logs showing staff were oriented to the new language.

   Low-cost method: Adjust existing scripts and train during regular staff meetings; no new tools required.

Together, these controls help a small practice demonstrate to payers, regulators, and auditors that balance-billing decisions are structured, not ad hoc. Folding them into HIPAA and revenue-cycle reviews ensures that No Surprises Act compliance is part of your overall risk program rather than a separate silo.

Case Study

A four-physician orthopedic group practices in an office attached to a community hospital and occasionally admits patients for surgery at the main hospital campus. The group has contracts with several major plans, but not all. Historically, when the surgeons operated on out-of-network patients at the hospital, they billed the patient the difference between the charge and plan payment, assuming the hospital’s in-network status did not affect their own billing.

After the No Surprises Act takes effect, a patient with group coverage receives an emergency department evaluation for a fracture and then an urgent surgical procedure at the hospital. The orthopedic group is out of network for this plan. The surgery is performed during the same stay, and the patient is discharged. The group balance bills the patient thousands of dollars above in-network cost sharing. The patient files a complaint, citing online information about surprise-billing protections.

The plan and state regulator review the facts. They determine that:

• The hospital meets the definition of a “health care facility” for non-emergency services and functions as an emergency department for the initial care.

• The orthopedic group was an “out-of-network provider” furnishing items and services in connection with emergency services and related facility-based care, bringing the encounter under 45 CFR 149.110 and 149.120.

• The group did not comply with the applicable balance-billing prohibitions and could not rely on any notice-and-consent exception given the timing and clinical context.

The regulator requires the group to refund all balance-billed amounts, recalculate patient responsibility based on in-network cost sharing, and review past similar cases. The group spends significant time and money working through the audit and negotiating a corrective plan.

After this event, the group implements an applicability map and red–yellow–green matrix based on 45 CFR 149.30 and Subpart B. Office-only visits in their stand-alone clinic remain mostly “green.” Any services tied to the hospital campus, especially those beginning in the emergency department or involving hospital outpatient departments, are treated as “red” or “yellow” and routed through a balance-billing approval checkpoint. Within a year, complaints about surprise bills drop, payer disputes ease, and the group’s documentation aligns with the definitions plans and regulators are using.

Use this table to test whether your small practice has integrated 45 CFR 149.30’s definitions into daily operations and linked them to balance-billing protections.

Running this checklist on a regular cycle turns 45 CFR 149.30 from a static definition page into an active compliance tool. The more your documentation mirrors the regulatory vocabulary, the easier it is to resolve disputes in your favor.

Common Audit Pitfalls to Avoid Under 45 CFR 149.30

Auditors and payers frequently see balance-billing problems that start with misapplied definitions. Focusing on these pitfalls can sharply reduce your risk profile under 45 CFR Part 149.

• Misclassifying a location as “office-only” when it meets the definition of a health care facility for non-emergency services, leading to illegal balance billing under 45 CFR 149.120 when nonparticipating providers treat plan members there.

• Treating cost-sharing obligations as including balance billing, even though 45 CFR 149.30 explicitly excludes balance billing from cost sharing, which causes patients to exceed statutory out-of-pocket limits and triggers complaints.

• Ignoring the definition of out-of-network emergency facility and assuming only hospitals are covered, when freestanding emergency departments and certain other sites clearly fall under the definition and thus the emergency balance-billing protections in 45 CFR 149.110 and 149.410.

• Failing to recognize when state “specified laws” control cost-sharing and payment calculations, resulting in billing patterns that violate state-level surprise-billing frameworks even if they appear consistent with federal minimums.

• Not linking internal billing edits to 45 CFR 149.30 definitions, so system rules cannot distinguish between protected emergency/facility-based encounters and true out-of-network office visits, leading to inconsistent handling of similar claims.

By correcting these definitional missteps, small practices can significantly reduce the likelihood of formal complaints and payment disputes. Clarity at the definition level translates directly into cleaner claims, fewer recoupments, and better patient experiences.

Embedding the No Surprises Act into practice culture starts with ownership. Designate a single “NSA and Balance-Billing Lead” who understands both 45 CFR 149.30 and the operative Subpart B and Subpart E rules and can translate them into plain-language tools for staff. 

Training should be short but recurring. New hires in scheduling, front desk, and billing should be introduced to the balance-billing matrix and the basic idea that certain encounters are “no-balance-billing zones” based on 45 CFR 149.30 definitions. Annual refreshers can use real, de-identified cases where the matrix prevented or corrected a problem. 

Monitoring should focus on a small set of meaningful indicators: number of encounters categorized as red/yellow/green, number of patient complaints about surprise bills, frequency of payer disputes referencing No Surprises Act sections, and results of the self-audit checklist. Leadership reviews these metrics at least annually and documents any adjustments to workflow, scripts, or contracts. Over time, this governance approach normalizes compliance and makes it easier to explain your program to regulators and payers alike.

The new era of balance billing is not about memorizing every line of the No Surprises Act. For small clinics, it is about using 45 CFR 149.30 as a map: clearly defining what kind of provider and facility you are in each context and then using that map to decide when balance billing is off limits. When you line up definitions, payer contracts, and internal workflows with the protections in 45 CFR 149.110–149.130 and related sections, you greatly reduce the odds of a surprise-billing complaint or an expensive recoupment. 

To move from theory to practice, small clinics can prioritize a few concrete steps:

1. Build a concise NSA applicability map based on 45 CFR 149.30 that classifies every practice location and major service line.

2. Translate that map into a red–yellow–green balance-billing matrix and train staff on how to use it when scheduling, documenting, and billing.

3. Crosswalk your top payer contracts to the federal definitions and protections, so your team can see where contract terms and statute align or diverge.

4. Add a balance-billing approval checkpoint for high-risk scenarios, with a simple log that captures the CFR references supporting each decision.

5. Schedule a six-month follow-up self-audit using the checklist to confirm that definitions and protections are being applied as intended.

Recommended compliance tool: 

A shared “NSA Balance-Billing Binder” (digital or physical) containing your applicability map, matrix, scripts, and approval log templates, indexed to 45 CFR 149.30 and 149.110–149.130.

Advice: Pick one recent out-of-network episode, walk it through your new map and matrix, and adjust your workflows until that single case could withstand regulatory scrutiny from both a definition and billing standpoint.

• 45 CFR Part 149 – Surprise Billing and Transparency Requirements
  

• 45 CFR 149.30 – Definitions
  

• 45 CFR 149.110 – Preventing Surprise Medical Bills for Emergency Services
  

• 45 CFR 149.120 – Preventing Surprise Medical Bills for Non-Emergency Services Performed by Nonparticipating Providers at Certain Participating Facilities
  

• 45 CFR 149.130 – Preventing Surprise Medical Bills for Air Ambulance Services