Surprise bill dispute letter (No Surprises Act template)

Updated October 1, 2026 · How we write our guides

When to use it

Use this letter when an out-of-network provider bills you more than your in-network share for care the No Surprises Act likely protects. That includes emergency care, some care at in-network hospitals and surgery centers, air ambulances, and visits booked using a wrong plan directory. It asks for a corrected bill and a hold.

You got a bill from an out-of-network provider, and it's far more than your explanation of benefits (EOB) says you owe. If the No Surprises Act (NSA) applies, you should owe only your in-network share. This letter asks the provider to correct the bill and hold your account while it checks.

Not sure the law applies? Our guide on whether the No Surprises Act covers your bill walks through it. Our No Surprises Act check asks a few questions.

When to use this letter

Use it if you have private health insurance and 1 of these fits:

Emergency care. An out-of-network emergency room or emergency doctor billed you more than your in-network share.
Care at an in-network facility. An out-of-network provider, like an anesthesiologist, treated you during a visit to an in-network hospital, hospital outpatient department, or ambulatory surgical center.
Air ambulance. An out-of-network air ambulance billed you for the balance.
A wrong directory or phone answer. Your plan's provider directory, or its member services, told you the provider was in-network, and it wasn't.

This letter isn't the right fit for a ground ambulance bill, which the federal law generally doesn't cover. If you don't have insurance, see our guide to good faith estimate disputes.

Before you send it

Compare the bill with your EOB. When the law applies, your share should match what you'd owe in-network: your copay, coinsurance, and deductible.
Call the provider's billing office. Say you believe the No Surprises Act applies, and ask for a hold.
Call your insurer. Ask whether it processed the claim under the No Surprises Act. If it used out-of-network cost sharing, ask it to reprocess the claim.

If a call fixes it, you may not need the letter. If not, send it.

What to fill in

You'll need the account number, the date of service, and your EOB claim number. You'll also need 2 amounts: what the bill asks for and what your EOB says you owe.

Then pick the reason that fits from the table below, and type it into the reason field.

Your situation	What to write
Emergency care	"I got emergency care at [hospital name] on the date of service."
Out-of-network provider at an in-network facility	"You treated me during a visit to [facility name], which is in my plan's network. I didn't sign a notice and consent form."
Anesthesia, radiology, pathology, or lab work at an in-network facility	"You provided [type of care] during my visit to [facility name], which is in my plan's network. Providers of this care can't ask patients to give up these protections."
Air ambulance	"I was taken by out-of-network air ambulance on the date of service."
Wrong directory listing	"My plan's provider directory listed you as in-network when I booked this care. I've attached a dated screenshot."
Wrong answer from your plan	"My plan's member services told me you were in-network on [date]. The reference number is [number]."

If your plan is reprocessing the claim, fill in what your current EOB shows. Ask the provider to bill you only the amount on the new EOB.

Fill in your details

Optional. What you type stays on this page. We don't save it or send it anywhere.

Your name

Your address

Your city, state, ZIP

Today's date

Provider name

Provider billing address

Patient name

Account number

Date of service

Insurer name

EOB claim number

Reason the No Surprises Act applies

Amount due on bill

My share on the EOB

Your phone

Your email

What to attach

Send copies, never originals.

The bill
Your EOB for the same claim
For a directory or phone mistake: your dated screenshot, or your call notes with the date, name, and reference number
Any notice and consent form you signed

How to send it

Send the letter by certified mail with a return receipt, so you can track delivery. If the provider's patient portal takes messages, you can send it there and attach your copies.

Send a copy to your insurer too. Use the address or upload option on your insurer's website or the back of your insurance card. Keep a copy of everything, and note the date you sent it.

What happens next

The provider may send a corrected bill, wait for your plan to reprocess the claim, or write back to explain its view. Check that any new bill matches your share on your latest EOB.

If the provider won't correct the bill, call the No Surprises Help Desk at 1-800-985-3059, or submit a complaint online. Have your bill, a photo of your insurance card, your EOB, and any consent form you signed. Write down your confirmation number.

If your plan won't apply the law to your claim, you can appeal. Our guide on how to appeal an insurance denial explains the steps. For anesthesia bills, see our guide to out-of-network anesthesia bills. For directory mistakes, see how to check if a doctor is in network.

Your state may have its own surprise billing law, too. State rules may add more protections.

Common questions

Who can use this letter?

It's for people with private health insurance: a plan through an employer, the Health Insurance Marketplace, or a plan you bought on your own. Medicare, Medicaid, TRICARE, the Indian Health Service, and Veterans Affairs have their own protections against surprise bills. If you have one of those, call your program or plan about a bill that seems wrong.

What if I signed a form agreeing to out-of-network care?

For some planned care, an out-of-network provider can ask you to sign a notice and consent form. You never have to sign it. No provider can ask for emergency care. Anesthesiologists, radiologists, pathologists, neonatologists, assistant surgeons, hospitalists, intensivists, and lab and other diagnostic providers at an in-network facility can't ask at all. Send the letter and ask for a copy of the form.

What if my plan's directory said the doctor was in-network?

If you have private insurance and relied on your plan's provider directory, federal law says your plan can't charge you more than your in-network cost sharing. The same is true if your plan told you by phone that the provider was in-network. Send your dated screenshot or call notes to your plan and ask it to reprocess the claim. Then send this letter to the provider.

Does this letter work for a ground ambulance bill?

Usually not. Ground ambulance rides generally aren't covered by the federal surprise billing protections, so an out-of-network ground ambulance may still bill you more. Some states have their own rules. Call your state insurance department to ask. Air ambulance rides are covered when you have private health insurance.

Who do I contact if the provider won't fix the bill?

Call the No Surprises Help Desk at 1-800-985-3059, or submit a complaint online. Have your bill, a photo of your insurance card, your explanation of benefits, and any consent form you signed. Write down the confirmation number you get. Your state insurance department can also explain any state surprise billing law.

Sources

Know your rights with insurance, Centers for Medicare & Medicaid Services. Accessed October 1, 2026.
42 U.S. Code § 300gg-115: Protecting patients and improving the accuracy of provider directory information, U.S. Government Publishing Office. Accessed October 1, 2026.
Submit a complaint, Centers for Medicare & Medicaid Services. Accessed October 1, 2026.
Reading your explanation of benefits (EOB), Centers for Medicare & Medicaid Services. Accessed October 1, 2026.

This is general information, not legal or medical advice. Rules can depend on your plan and your state. Romi Care isn't an insurer, law firm, collection agency, or government program.