The federal No Surprises Act protects most patients from out-of-network balance billing for emergency care and for out-of-network care received at an in-network facility — in those situations, you generally owe only your in-network cost-sharing amount. This free template asserts that protection directly to the billing provider and requests a corrected bill.
A full letter you can copy: patient and account identifiers, a section describing the emergency or out-of-network-at-in-network-facility circumstances, a request for a corrected itemized statement, and a note that a complaint can be filed with the federal No Surprises Help Desk at cms.gov/nosurprises or 1-800-985-3059.
Ground ambulances are generally NOT covered by the federal No Surprises Act (though some states protect them separately); uninsured/self-pay patients have a related Good Faith Estimate dispute process for bills $400 or more over the estimate, generally within 120 days.
Medigami's $149 Bill Rescue service reviews your bill and drafts the dispute for you — done in 48 hours. You review, sign, and submit it yourself.
Educational free template only. Not legal advice. Consult a licensed attorney or your state insurance department about your specific situation.
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We check any medical bill against standard Medicare rates and flag overcharges, duplicates, and billing mistakes — in about 60 seconds.
Built for fertility patients: we check every line of an IVF bill, flag low-value add-ons, and include a cost estimator that uses your state's rules plus a clinic finder.
Educational tool — not legal, medical, or billing-counsel advice. Treatment and appeal decisions remain with you and your physician / counsel.