We read what they sent you.

Subject: Math Reconciliation Error — Account #[ACCOUNT]

Dear Billing Department,

On account #[ACCOUNT], the bill's math does not reconcile.

From the bill itself:
  Total charged:               ${CHARGED}
  Less insurance adjustment:   ${ADJUSTMENT}
  Less insurance payment:      ${INS_PAID}
  Less my prior payments:      ${PRIOR_PAID}
  Computed patient owed:       ${COMPUTED}
  Stated patient owed on bill: ${STATED}
  Discrepancy:                 ${DIFFERENCE}

The stated patient responsibility is ${DIFFERENCE} higher than the computed amount. I am requesting:

1. A corrected statement showing how every dollar is accounted for. Any adjustments, fees, taxes, or interest must be explicitly itemized — not folded into a single 'patient responsibility' figure.

2. If the corrected statement does not reconcile to ${COMPUTED} or lower, a written explanation of every line that contributes to the difference, including:
   - The CPT/HCPCS/revenue code or basis for the additional charge
   - The date it was incurred
   - Why it does not appear elsewhere on the bill

I am paying ${COMPUTED} now as the undisputed amount. The disputed ${DIFFERENCE} is on hold pending a corrected statement.

Thank you,
[NAME]

Subject: No Surprises Act Dispute — Account #[ACCOUNT] — Out-of-Network Balance Bill

To Whom It May Concern,

I am disputing the charges on the above account under the federal No Surprises Act (Public Law 116-260, Division BB, Title I; implementing regulations at 45 CFR 149).

Facts:
- Date of service: [DOS]
- Facility: [FACILITY], which was in-network on my [INSURANCE PLAN] plan on the date of service.
- Provider: [PROVIDER NAME, NPI if known], who billed me at out-of-network rates.
- I [did not / did] receive a 'Notice and Consent to Balance Bill' form 72 hours or more before the service.
- Service type: [emergency / non-emergency at in-network facility / air ambulance].

Under the No Surprises Act, I am protected from balance billing for this service. My responsibility is limited to the in-network cost-sharing amount under my plan, which is [AMOUNT, from EOB].

I request:
1. The provider rebill this claim under in-network rates, OR
2. The insurer and provider initiate the federal Independent Dispute Resolution (IDR) process to determine the appropriate out-of-network rate. I am NOT to be charged above my in-network cost-sharing during this process.

If this dispute is not resolved within 30 days, I will file a complaint with the CMS No Surprises Help Desk (1-800-985-3059, cms.gov/nosurprises/consumers).

Thank you,
[NAME]
[DATE]

{see shared_resources.itemized_bill_request_letter_template}

Subject: HIPAA Right of Access Violation — Account #[ACCOUNT]

Dear [Hospital Privacy Officer / Compliance Officer],

On [DATE], I submitted a HIPAA Right of Access request (45 CFR 164.524) for an itemized statement of charges on account #[ACCOUNT]. It has now been [N] calendar days and I have not received the requested records.

Under federal law, hospitals must respond to a HIPAA Right of Access request within 30 calendar days, with at most one 30-day extension if formally communicated in writing.

If I do not receive the itemized statement within 7 business days of this letter, I will file a complaint with:
- The U.S. Department of Health and Human Services, Office for Civil Rights (HHS OCR), which has authority to impose fines under HIPAA enforcement provisions
- My state Department of Insurance
- My state Attorney General's office

Thank you,
[NAME]
[DATE]

Subject: Disputed Charges on Itemized Bill — Account #[ACCOUNT]

Dear Billing Department,

Following receipt of the itemized statement for account #[ACCOUNT] on [DATE], I am formally disputing the following charges:

[LIST 3-5 OVERPRICED ITEMS, EACH ON ITS OWN LINE:]
- [Date]: [Item] — billed [Amount]. Retail/Medicare benchmark: [Comparison]. Disputed amount: [Difference].

Total disputed: [TOTAL]

Grounds for dispute:
- These charges exceed reasonable market rates by [Xx multiple of Medicare/retail].
- Some items appear to be duplicate (see specifics above).
- Some quantities are inconsistent with the documented care.

I request:
1. Documentation justifying these specific charges (manufacturer invoices for supplies, pharmacy NDC pricing for drugs).
2. Adjustment of disputed items to reasonable market value.
3. A revised statement reflecting the adjustments.

I am paying the undisputed portion of [AMOUNT] now. The disputed [DISPUTED AMOUNT] is on hold pending review. Please do not refer this account to collections during the dispute.

Thank you,
[NAME]

{see shared_resources.itemized_bill_request_letter_template}, but request the MEDICAL RECORD for [DOS], specifically the physician's note documenting medical decision-making, history obtained, examination performed, and time spent.

Subject: E/M Code Up-Coding Dispute — Account #[ACCOUNT]

Dear Billing Department,

On account #[ACCOUNT] for services on [DOS], the bill includes CPT [BILLED_CODE] ([CODE_DESCRIPTION]). I have reviewed the medical record for this visit and the documentation does not support this complexity level.

From the medical record:
- Time documented: [X] minutes (CPT [BILLED_CODE] requires [Y]+ minutes per AMA guidelines)
- Medical decision-making documented: [LOW/MODERATE/HIGH] complexity (CPT [BILLED_CODE] requires [HIGH/MODERATE/etc.])
- Number of problems addressed: [N] (CPT [BILLED_CODE] typically requires [N+1] or more)
- Risk level: [LEVEL] (CPT [BILLED_CODE] typically requires [HIGHER LEVEL])

Based on the documented care, the appropriate CPT is [LOWER_CODE] ([DESCRIPTION]), with a charge difference of approximately ${DIFFERENTIAL}.

I request:
1. The bill be corrected to reflect the appropriate CPT based on documentation
2. A revised statement with the corrected charge
3. If the original code is maintained, written justification citing specific elements of the medical record

I am paying the undisputed portion of [AMOUNT]. The disputed [DIFFERENTIAL] is on hold pending review.

Thank you,
[NAME]
[DATE]

Subject: Billing Review Request — Account #[ACCOUNT] — Duplicate Charge

Dear Billing Department,

Following my call on [DATE] with [REP NAME, if obtained], I am formally requesting a billing review for account #[ACCOUNT] for services on [DOS].

Specifically, I am disputing the following duplicate line item:
- {cpt_or_description} appears on lines {line_refs}, both billed at [AMOUNT] for the same date of service.

Unless the medical record documents that this procedure was actually performed twice during this encounter, please remove the duplicate charge and issue an updated statement.

I am paying the undisputed portion of this bill. The amount under dispute is [DUPLICATE AMOUNT]. Please do not refer this account to collections while the billing review is in progress.

Please confirm receipt and provide a ticket or case number for tracking.

Thank you,
[NAME]
[DATE]
[CONTACT INFO]

Subject: Pre-Authorization Failure — Account #[ACCOUNT]

Dear Billing Department,

On [DOS] I received services at [FACILITY] under account #[ACCOUNT]. My insurance plan ([PLAN NAME]) denied coverage on the grounds that pre-authorization was not obtained for [PROCEDURE / CPT {code}].

Per my conversation with [INSURER] on [DATE], pre-authorization for this service was required. As the treating facility, [FACILITY] was responsible for verifying my insurance benefits and obtaining pre-authorization before performing the procedure.

The facility's failure to obtain required pre-authorization is an administrative error. This charge should not be transferred to me as the patient. I request:

1. The facility submit a retroactive pre-authorization request with medical necessity documentation, OR
2. The facility absorb the denied charge as a billing/coding office responsibility, OR
3. Provide written documentation showing that pre-authorization was attempted and the failure was outside your control (e.g., emergency situation where pre-auth was not possible).

I am not paying ${AMOUNT} for a service denied due to a facility administrative oversight.

Thank you,
[NAME]
[DATE]