Balance Billing Dispute Letter Template

When to Use This Template

Use this letter when you receive:

• A bill from an out-of-network provider at an in-network facility
• Balance bill after emergency room treatment
• Surprise bill from an out-of-network anesthesiologist, radiologist, or pathologist
• Air ambulance balance bill

Template

[Your Name] [Your Address] [Date] [Provider/Billing Company Name] [Address] Re: Balance Billing Dispute — No Surprises Act Account Number: [Account #] Date of Service: [Date] Amount Disputed: $[Amount]

Dear Billing Department,

I am writing to dispute the balance bill of $[amount] for services provided on [date] at [facility name]. This bill violates the No Surprises Act (Public Law 116-260), which prohibits balance billing in the following circumstances:

Applicable Protection:

[Choose the relevant scenario:]

☐ Emergency Services — I received emergency services and cannot be balance billed regardless of the provider's or facility's network status.

☐ Non-Emergency at In-Network Facility — I received non-emergency services from an out-of-network provider at [in-network facility name] without being given proper notice or providing informed consent to out-of-network billing.

☐ Air Ambulance — I received air ambulance transport from an out-of-network provider.

Under the No Surprises Act, I am only responsible for in-network cost-sharing amounts. My insurance plan has been billed for these services. Any remaining balance between the in-network allowed amount and your charges must be resolved through the federal independent dispute resolution (IDR) process between you and my insurer — not billed to me. Requested Action:

1. Withdraw this balance bill immediately
2. Pursue payment through the IDR process with my insurer, [insurance company name]
3. If you believe the No Surprises Act does not apply, provide a written explanation of why

If this balance bill is not withdrawn within 30 days, I will file a complaint with CMS at 1-800-985-3059.

Sincerely, [Your Name]

Important Notes

• Keep a copy of the original bill as evidence
• Document the timeline of communications
• File a complaint with CMS if the provider does not comply