Key points
- This site found no general federal law that requires an itemized bill for insured patients. Many states have their own rules.
- The federal health privacy rule gives you a right to a provider's billing records, which a provider must act on within 30 days, with one extension of up to 30 more days.
- After a denial, a plan that is not grandfathered must give you the diagnosis and treatment codes and their meanings on request.
- Compare the itemized bill with your Explanation of Benefits before you pay, and ask the provider to correct errors and resend the claim.
An itemized bill lists every charge on your account: what was done, when, the billing code and the price. Ask for it before you pay or dispute a bill, then compare it line by line with your plan’s Explanation of Benefits (EOB). You may not have a federal right to the itemized bill itself. You do have a right to the provider’s billing records, and that gets you the same information.
What this means
This site looked for a general federal law that requires a provider to give an insured patient an itemized bill and did not find one. That is a negative finding, so treat it as “not confirmed” rather than “does not exist”. Many states have their own rules, and some providers give an itemized bill on request as a matter of course.
Two federal rights do help:
- Billing records from the provider. Under the federal health privacy rule, the Health Insurance Portability and Accountability Act (HIPAA), a provider must act on your request for your own records, which include billing records, within 30 days. It may extend that once, by up to 30 more days, if it explains the delay in writing. It may charge only a reasonable, cost-based fee.
- Codes after a denial. If your plan denied the claim and it is not grandfathered, it must provide the diagnosis code, the treatment code and what they mean, as soon as practicable after you ask. Asking for the codes cannot be treated as filing an appeal.
An EOB is not a bill. The itemized bill shows what the provider charged. The EOB shows what your plan decided. Errors often show up in the gap between them.
What to do
- Gather both papers (your step). Collect the bill or statement and the EOB for the same date of service. If you do not have the EOB, see how to read an EOB.
- Ask for the itemized bill. Call the provider’s billing office first, then confirm in writing with the itemized bill request letter. Ask for each charge with the date of service, a description, the billing code, the amount charged, the amount billed to your plan, each payment and adjustment, and the balance. Ask for a copy of the claim as it was sent to your plan.
- Send it so you can prove it. Use the address, fax or portal printed on the bill. Keep the confirmation. Write down the date, the person’s name and any reference number from any call.
- Hold off on paying the full balance. Unless the provider tells you in writing what it will do about collections, do not pay the full amount until you have the itemized bill. If the bill is tied to an appeal, ask the provider to hold the account while the appeal is pending. See the bill while you appeal and the bill hold request letter.
- Compare line by line. Match each charge on the itemized bill to a line on the EOB. Mark anything you do not recognize, anything charged twice, and any code that does not match the care you received.
- Contact the billing office (your step). If a charge is wrong, ask the provider to correct it and resend the claim to your plan. Coding mistakes are usually the provider’s to fix, not yours.
- Keep your appeal deadline in view. If the plan denied the claim, you have at least 180 days after you receive the denial notice to appeal, and your plan may allow more. Check the date on your notice, which controls.
Errors to look for
The Arthritis Foundation lists nine common billing errors:
- wrong patient information;
- an incorrect code;
- transposed numbers;
- a duplicate charge;
- a service you did not receive;
- unbundled charges (items billed separately that belong together);
- upcoding (a code for more care than was given);
- incorrect balance billing (billing you for an amount you do not owe); and
- diagnosis and treatment codes that do not match.
What the office may say, and what to say back
“We do not provide itemized bills.” Ask for your billing records under your right of access to your own records, and ask for the answer in writing. The records include the charges, codes and payments.
“The statement is itemized.” Check that it lists the billing code for each charge and each payment and adjustment. A summary total is not itemized.
“Your insurance should have paid.” Ask for a copy of the claim as sent to your plan, then compare it with the EOB. If the claim was wrong, ask the office to correct it and resubmit.
The rule
A provider must act on an individual’s request for their own records, including billing records, within 30 days (one extension of up to 30 more days with a written explanation), and may charge only a reasonable, cost-based fee. See section 164.524 of Title 45 of the Code of Federal Regulations (CFR): 45 CFR 164.524.
Watch for
- State rules. Your state may require an itemized bill. Check your state page and ask the provider.
- A bill that does not match the plan’s decision. If your plan said you owe less than the provider billed, say so and ask the provider to explain the difference.
- Surprise bills. If the bill came from an out-of-network clinician at an in-network hospital, different rules may apply. See surprise bills.
- Collections. If the bill has gone to a collector, see medical debt in collections.
What next
- Coding and billing errors: how to fix a denial caused by a code.
- The bill while you appeal: how to protect yourself from collections during an appeal.
- How to negotiate a medical bill: what to do if the bill is right but you cannot pay it.