This letter asks the provider to check whether the federal No Surprises Act applies to your bill, to correct it if it does, and to hold the account meanwhile.
[Your name]
[Your mailing address]
[Today's date]
[Billing office name]
[Billing office address]
Re: Request for review of a surprise bill. Patient: [Patient name]. Account: [Account number]. Date of service: [Date of service].
To the billing office:
I received a bill for [amount] for care on the date above at [hospital or facility]. Please review whether this bill is subject to the federal No Surprises Act, and if it is, correct it as the Act requires.
If you believe the Act does not apply, please explain why in writing, and send me a copy of any notice and consent form I signed about out-of-network care.
Please hold this account, and do not send it to a collection agency, while this is reviewed.
Thank you,
[Your name]
Balance billing, worked
An out-of-network doctor charges $2,000. Your plan allows $800 and pays $640. A balance bill asks you for the other $1,360 ($2,000 minus $640). In this example, your share of the allowed amount is $160 ($800 minus $640).
Check CMS's page
The Centers for Medicare & Medicaid Services (CMS) explains which bills the No Surprises Act covers, and how to complain or ask its help desk about a bill, on its medical bill rights page. More on where to turn is on the out-of-network guide.
Gather this first
- The bill, and the itemized bill.
- Your insurer's EOB for the same date.
- Any notice or consent form you signed about out-of-network care.
Questions people ask next
What is balance billing?
A provider billing you for the difference between its full charge and what your plan paid. It can happen when the provider is outside your plan's network.
What is the No Surprises Act?
A federal law that protects people from some surprise bills, such as many emergency bills and some bills from out-of-network providers at in-network hospitals. CMS explains which bills it covers.
Does it cover ambulance bills?
Check CMS's medical bill rights page for which services are covered before you send the letter.
I'm uninsured and the bill is above my estimate. Is this the right letter?
No. That case has its own dispute process; see the guide for self-pay bills over the estimate.
For the phone calls
The Medical Bill Fight Kit
A 9-page PDF you print: the order of steps, word-for-word call scripts for the billing office, your insurer, financial assistance and a collection agency, five letters with blanks (the three free ones here, plus a financial assistance request and a payment agreement confirmation) and a call and mail log.
$9 Buy the kit
If the file doesn't work or isn't what this page describes, write to us within 14 days for a full refund.
Bill Pushback