Appeal letter template
Balance billing dispute (in-network provider)
Use when an in-network provider has billed you the gap between their billed amount and your insurance’s allowed amount. By contract, in-network providers cannot pass that gap to you.
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11 fields blank{{your_name}}
{{your_address}}
{{provider_name}}
Billing Department
{{provider_address}}
Re: Balance billing dispute - account {{your_account}}, date of service {{visit_date}}
To whom it may concern,
I'm disputing a balance-bill charge on the above account. According to the Explanation of Benefits issued by {{insurer_name}}, the allowed amount for the services I received was {{allowed_amount}}, of which my patient responsibility (deductible / coinsurance / copay) is {{patient_responsibility}}. Your bill, however, charges me {{billed_amount}}.
As an in-network participating provider, your contract with {{insurer_name}} prohibits balance billing — you may not bill me for the difference between your charge and the insurer's allowed amount.
I'm requesting:
1. Reversal of the balance-bill portion of this charge.
2. A corrected statement showing only my true patient responsibility per the EOB.
If this charge is not adjusted, I will file a complaint with {{insurer_name}}'s provider-relations department citing breach of network contract.
Please respond in writing within 30 days.
Sincerely,
{{your_name}}