No Surprises Act Dispute - Surprise Medical Bill

Instructions for Use

The No Surprises Act (effective January 1, 2022) protects patients from unexpected medical bills in specific situations. This template is for disputing surprise medical bills under the Act's patient protections.

You Are Protected From Balance Billing For:
- Emergency services (regardless of network status)
- Non-emergency services at in-network facilities from out-of-network providers (unless you gave written consent)
- Air ambulance services from out-of-network providers

For Uninsured/Self-Pay Patients:
- You must receive a Good Faith Estimate before scheduled services
- If your bill exceeds the estimate by $400 or more, you can dispute it

Part A: Insured Patient - Surprise Billing Protection

Use this section if you have health insurance and received a surprise bill

Dispute Request

[Date]

VIA CERTIFIED MAIL AND EMAIL

[Healthcare Provider/Facility Name]
[Billing Department]
[Street Address]
[City, State, ZIP]

CC: [Insurance Company Name], [Address]

Re: Dispute Under No Surprises Act

Dear Billing Department:

I am writing to dispute the above-referenced medical bill under the No Surprises Act (Consolidated Appropriations Act, 2021), which took effect January 1, 2022. I believe this bill violates federal protections against surprise medical billing.

Section 1: Type of Protected Service

This bill involves (check all that apply):

☐ Emergency Services - I received emergency care and am being balance billed by an out-of-network provider

☐ Non-Emergency Services at In-Network Facility - I received care at an in-network facility but am being billed by an out-of-network provider who treated me at that facility

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

☐ I Did Not Consent to Out-of-Network Care - I was not provided proper notice and did not sign a valid consent to balance billing

Section 2: Circumstances of Service

Type of Service:
☐ Emergency room visit
☐ Inpatient hospital stay
☐ Outpatient surgery
☐ Diagnostic services (lab, imaging)
☐ Anesthesiology services
☐ Radiology services
☐ Pathology services
☐ Assistant surgeon services
☐ Air ambulance transport
☐ Other: ______________________________________________

Location of Service:

Provider Who Sent Bill:

Section 3: Billing Violation Details

Amount Breakdown:

The No Surprises Act Violation:

☐ Improper Balance Billing - Provider is billing me more than my in-network cost-sharing amount (copay, coinsurance, deductible)

☐ Emergency Services Balance Bill - Provider is balance billing for emergency services when the law prohibits this

☐ Non-Consented Out-of-Network Billing - I did not receive proper notice and consent before receiving out-of-network care at an in-network facility

☐ Invalid Consent - The consent form I signed was defective because:
☐ Not provided 72 hours in advance (for scheduled services)
☐ Not provided 3 hours in advance (for same-day services)
☐ Did not include good faith estimate of charges
☐ Did not list in-network alternatives
☐ I was not able to choose an in-network provider
☐ Services were "ancillary" (anesthesiology, pathology, radiology, etc.)
☐ Service was unforeseen urgent medical need during scheduled service

Section 4: Legal Basis for Dispute

Under the No Surprises Act:

For Emergency Services (42 U.S.C. § 300gg-111(a)):
- Out-of-network providers cannot balance bill patients
- Patient cost-sharing must be calculated as if provider were in-network
- Provider must accept in-network cost-sharing as payment in full

For Non-Emergency Services at In-Network Facilities (42 U.S.C. § 300gg-111(b)):
- Out-of-network providers cannot balance bill unless patient gives informed consent
- Consent must be obtained 72 hours in advance (or 3 hours for same-day)
- Consent not permitted for ancillary services or unforeseen urgent needs
- Patient cost-sharing calculated at in-network rate absent valid consent

For Air Ambulance (42 U.S.C. § 300gg-112):
- Out-of-network air ambulance providers cannot balance bill
- Patient cost-sharing calculated at in-network rate

Section 5: Demand

Based on the No Surprises Act protections, I demand that you:

1. Cease all balance billing for the protected services identified above

2. Recalculate my patient responsibility based on my plan's in-network cost-sharing (copay, coinsurance, deductible) only

3. Provide corrected bill showing only the amount I legitimately owe under the law

4. Pursue any payment dispute with my insurance company through the Independent Dispute Resolution (IDR) process, not by billing me

5. Confirm in writing that this account will not be sent to collections or reported to credit bureaus

Response requested within 30 days.

Part B: Uninsured/Self-Pay Patient - Good Faith Estimate Dispute

Use this section if you are uninsured or self-pay and received a bill exceeding your Good Faith Estimate by $400 or more

Patient-Provider Dispute Resolution Request

[Date]

To initiate dispute, file online at: https://disputes.cms.gov/patient-provider-form

Or mail to:
CMS Patient-Provider Dispute Resolution
[Address per CMS guidance]

Re: Patient-Provider Dispute Under No Surprises Act

Section 1: Good Faith Estimate Information

Note: You may dispute if the difference is $400 or more.

Section 2: Services Covered by Estimate vs. Bill

Services Listed in Good Faith Estimate:

Services on Actual Bill:

Section 3: Reason for Dispute

Check all that apply:

☐ Bill exceeds Good Faith Estimate by $400 or more
☐ Bill includes services not listed in Good Faith Estimate
☐ Charges are higher than what was estimated
☐ I did not receive a Good Faith Estimate as required
☐ Good Faith Estimate did not include all expected services
☐ Other: ______________________________________________

Detailed Explanation:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Section 4: Documentation Submitted

☐ Copy of Good Faith Estimate received
☐ Copy of itemized bill
☐ Proof that I am uninsured/self-pay
☐ Any correspondence with provider
☐ Payment of $25 administrative fee (required)

Section 5: Requested Resolution

☐ I request that my bill be reduced to match the Good Faith Estimate
☐ I request that charges for services not in the estimate be removed
☐ Other resolution sought: ______________________________________________

Patient-Provider Dispute Resolution Process Information

Eligibility Requirements

To use the Patient-Provider Dispute Resolution (PPDR) process:
1. You must be uninsured OR chose to self-pay
2. You received (or should have received) a Good Faith Estimate
3. Your final bill exceeds the estimate by $400 or more
4. Service was provided on or after January 1, 2022

How to File

1. Online: https://disputes.cms.gov/patient-provider-form
2. Payment: $25 non-refundable administrative fee
3. Deadline: Within 120 days of receiving the bill

What Happens Next

1. Your dispute is assigned to a Selected Dispute Resolution (SDR) entity
2. Provider is notified and has opportunity to respond
3. SDR entity reviews Good Faith Estimate and bill
4. Decision issued within 30 business days
5. Decision is binding on provider

Fee Refund

If the SDR entity determines the bill should be reduced:
- The $25 fee is applied toward your bill
- You only owe the reduced amount

Contact Information

CMS No Surprises Help Desk:
- Phone: 1-800-985-3059
- Hours: 8 AM - 8 PM ET, 7 days a week
- Email: [email protected]
- Website: https://www.cms.gov/nosurprises

To File Complaint About Provider/Insurer Violation:
- CMS Complaint Portal: https://www.cms.gov/nosurprises/consumers/complaints

Patient Signature and Certification

I certify that the information provided is true and accurate to the best of my knowledge. I understand:
- A $25 administrative fee is required for patient-provider disputes
- The SDR entity's decision is binding on the provider
- Filing a dispute does not guarantee a reduction in my bill

Signature: ______________________________________________

Printed Name: ______________________________________________

Date: ______________________________________________

Tracking

Resources

• CMS No Surprises Act: https://www.cms.gov/nosurprises
• Patient Rights Overview: https://www.cms.gov/nosurprises/consumers
• Good Faith Estimate Information: https://www.cms.gov/nosurprises/consumers/understanding-costs-in-advance
• File a Complaint: https://www.cms.gov/nosurprises/consumers/complaints
• CFPB Surprise Billing: https://www.consumerfinance.gov/ask-cfpb/what-is-a-surprise-medical-bill-en-2123/

This template is provided for informational purposes only and does not constitute legal advice. Consult with a healthcare attorney for specific legal guidance.