Tell the provider the No Surprises Act may apply to your bill
Write to the provider's billing office to say the federal No Surprises Act may apply, ask them to bill only your in-network share, hold the account while your plan reprocesses the claim, and confirm in writing.
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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. For someone with a job-based or individual plan (including a Marketplace plan) who received a bill for emergency care, for care from an out-of-network clinician at an in-network hospital or surgical center, or for an air ambulance flight, and who thinks it may be a surprise bill. It is not for Medicare or Medicaid, and it does not cover ground ambulance. Do not pay yet. Send it with a copy of your plan's explanation of benefits. A provider does not have to agree to hold a bill, but many do when asked in writing.
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
[Name and address of the provider's billing office]
Re: Tell the provider the No Surprises Act may apply to your bill Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To the billing office:
I am writing about my account [Account number on the bill] with [Doctor, hospital or pharmacy] for services on [Date of the care]. The balance shown is [Balance shown on the bill].
I have health coverage with [Name of the health plan]. My plan's explanation of benefits (EOB) for these services is enclosed. I believe the federal No Surprises Act may apply to this bill. The Act may limit what an out-of-network provider can bill a patient for emergency services, for care by an out-of-network clinician at an in-network hospital or surgical center, and for air ambulance services. If it applies, I may be billed no more than my in-network cost sharing (my copay, coinsurance or deductible share).
I am not refusing to pay what I owe. I am asking you to check this bill before I pay anything. Please: 1. Check whether the No Surprises Act applies to these services. 2. If it does, bill me only the in-network cost sharing that my plan shows after it reprocesses the claim, and send me a corrected bill. 3. Put this account on hold while my plan reprocesses the claim. Do not send it to a collection agency, report it to a credit reporting company or add late fees during the hold. I understand a hold is a courtesy and that you may not be required to give one. 4. Confirm the hold in writing, and tell me the name of the person who handled my request.
I am also asking my plan to reprocess the claim. You can reach me at [A phone number where you can be reached].
Enclosures: 1. Copy of my plan's explanation of benefits (EOB) 2. Copy of the bill
Sincerely, [Your name]
Before you send it
Send it to the provider's billing office, at the address on the bill, by mail with tracking or by the billing portal if it gives a receipt. Then call and ask whether they received it. Write down the name of the person, the date, the time and a reference number. If you want to call first, see the phone script for the billing office.
What to enclose
- Copy of my plan's explanation of benefits (EOB)
- Copy of the bill
What happens next
- A provider does not have to agree to a hold, and the sources behind this site list no federal rule that makes a provider hold a bill while your plan reprocesses a claim. Ask, get the answer in writing and keep it.
- Send the matching letter to your plan, asking it to reprocess the claim with the No Surprises Act protections (“Ask your plan to reprocess a claim under the No Surprises Act”).
- For services the Act protects, the plan must decide whether they are covered and send the provider an initial payment or a notice of denial within 30 calendar days after it has the information it needs.
- If the Act applies, you owe only your in-network cost sharing, and that cost sharing counts toward your in-network deductible and out-of-pocket maximum. Any payment dispute between your plan and the provider is between them.
- The Act does not cover ground ambulance, and it does not cover short-term limited-duration plans, health care sharing ministries or fixed indemnity plans.
- To complain, call the No Surprises Help Desk at 1-800-985-3059 or use the online complaint form. See the complaint letter (“No Surprises Act complaint”).
- If you have no insurance or are paying yourself, a different process applies. You may dispute a bill that is at least $400 more than the provider's good faith estimate, and you must start within 120 calendar days of receiving the initial bill.
- The rules on collectors, interest, lawsuits and credit reports are set by consumer-debt law, and this site has not verified them. Before you rely on any deadline or right, confirm the current rules with the Consumer Financial Protection Bureau or a consumer-law legal aid office.
The rule behind this
Sources
Denial reasons this answers
- Denial reason
Out of network
The plan says your provider or facility is not in its network. Federal law protects you in emergencies and in several hospital situations, so check which situation you are in before you pay.