No Surprises Act complaint
Tell the federal government that you were billed more than the No Surprises Act allows, using the No Surprises Help Desk or the online complaint form.
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- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. When a provider or facility billed you more than your in-network cost sharing for emergency care, for an out-of-network clinician at an in-network facility, or for an air ambulance, or when your plan will not apply those protections. Ground ambulance bills are not covered by the Act, and neither are short-term, health care sharing ministry and fixed indemnity plans. A complaint does NOT stop an appeal deadline. The sources this site uses confirm that the Act applies to Federal Employees Health Benefits plans. For other federal coverage, such as TRICARE, Veterans Affairs or Indian Health Service, ask your plan or program whether the Act applies; this is not confirmed here.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Where you are filing: the No Surprises complaint form or the office named on it]
Re: No Surprises Act complaint Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To whom it may concern:
I am filing a complaint under the No Surprises Act, the federal law that limits surprise medical bills.
I was billed [Amount you were billed] by [Doctor, hospital or pharmacy] for [The care or drug that was denied], provided on [Date of the care]. My plan is [Name of the health plan], member identification (ID) number [Member ID], claim number [Claim or reference number].
What happened: [What happened, in order, with dates]
I believe I was billed more than my plan's in-network cost sharing for care that the Act protects. I am asking for your help because I do not believe I should have to pay this amount. I have enclosed the bill, my Explanation of Benefits and any notices I received, so that you can see what I was charged and what my plan paid.
I ask that you: 1. Review whether [Doctor, hospital or pharmacy] or my plan broke the rules of the Act. 2. Tell me in writing what you find. 3. Tell me what to do about the bill while you review it. 4. If the Act applies, see that I am asked to pay no more than my in-network cost sharing.
Enclosures: 1. Copy of the bill 2. Your Explanation of Benefits 3. Any denial notice from your plan 4. A screenshot or copy of the provider directory, if relevant
Sincerely, [Your name]
Before you send it
File online at the Centers for Medicare & Medicaid Services complaint page (cms.gov/medical-bill-rights/help/submit-a-complaint), or call the No Surprises Help Desk at 1-800-985-3059. Paste or read this letter. Help is available in English, Spanish and more than 350 other languages. The pages we read did not state the Help Desk's hours, so ask when you call. Write down the reference number.
What to enclose
- Copy of the bill
- Your Explanation of Benefits
- Any denial notice from your plan
- A screenshot or copy of the provider directory, if relevant
What happens next
- The federal government must acknowledge a complaint within 60 business days. Keep your complaint number.
- Ask the provider in writing to hold the bill while the complaint is reviewed. See the bill hold letter on this site.
- If your plan denied a claim because it said the protections do not apply, you can appeal that denial and take it to external review, even if your plan is grandfathered.
- The payment dispute between your plan and an out-of-network provider is between those two parties. You are not a party to it, and you owe only in-network cost sharing.
- If you are uninsured or pay yourself, and a bill is at least $400 more than your good faith estimate, you can start a patient-provider dispute within 120 calendar days of receiving the initial bill. The fee is $25 as of 11 November 2026. While it is pending, the provider must not send the bill to collection or threaten to.
- If you are writing for someone else, tick "I am writing for someone else". The office you are writing to may require its own authorization form. See the letter "Name someone to act for you".