Appeal letter template
No Surprises Act protection
Use when you received care at an in-network hospital but an out-of-network provider (often anesthesiologist, ER doctor, radiologist) billed you separately at out-of-network rates.
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10 fields blank{{your_name}}
{{your_address}}
{{provider_name}}
Billing Department
{{provider_address}}
Re: No Surprises Act dispute - account {{your_account}}, date of service {{visit_date}}
To whom it may concern,
On {{visit_date}}, I received care at {{facility_name}}, which is in my insurance network. During that visit I was treated by your team ({{oon_provider_type}}), and have now received a bill for {{billed_amount}} at out-of-network rates.
This bill is prohibited under the federal No Surprises Act, 42 U.S.C. § 300gg-111. The Act protects patients from balance bills for out-of-network ancillary services performed at in-network facilities. My cost-sharing must be calculated as if your services were in-network, and you must work with my insurer to settle the remainder — not me.
I'm requesting:
1. Immediate adjustment of my bill to the in-network cost-sharing amount.
2. A corrected statement reflecting the No Surprises Act calculation.
3. Confirmation that you have submitted the appropriate IDR (Independent Dispute Resolution) request to my insurer for any remaining amount.
If you believe this dispute is incorrect, please cite the specific exception under the No Surprises Act that you are claiming. Otherwise, please correct this bill within 30 days.
I will also be filing a complaint with the CMS No Surprises Act help desk at 1-800-985-3059 if this matter is not resolved.
Sincerely,
{{your_name}}