No Surprises Act Out-of-Network Balance Billing Dispute

[CLIENT FULL NAME] [CLIENT ADDRESS LINE1] [CLIENT CITY], [CLIENT STATE] [CLIENT ZIP] DOB: [CLIENT DOB] | SSN (Last 4): [CLIENT SSN LAST4] Date: [TODAY] [RECIPIENT NAME] [RECIPIENT ADDRESS BLOCK] RE: DISPUTE OF UNLAWFUL OUT-OF-NETWORK BALANCE BILL UNDER NO SURPRISES ACT (42 U.S.C. § 300gg-111) - Account #[ACCOUNT ACCOUNT NUMBER MASKED] Dear Patient Financial Services / Compliance Department, I am formally disputing medical account #[ACCOUNT ACCOUNT NUMBER MASKED] in the amount of [ACCOUNT BALANCE] issued by [ACCOUNT CREDITOR NAME]. UNLAWFUL BALANCE BILLING UNDER THE NO SURPRISES ACT: The billed charge arises from medical services rendered on [HARDSHIP DATES] under emergency conditions or by an out-of-network ancillary provider at an in-network facility. Under the federal No Surprises Act (42 U.S.C. §§ 300gg-111 & 300gg-131): 1. Patients are protected from surprise balance billing for emergency services and non-emergency services provided by out-of-network clinicians at in-network facilities. 2. Patient cost-sharing cannot exceed the in-network cost-sharing amount determined by the Qualifying Payment Amount (QPA). 3. Out-of-network balance billing is illegal, and furnishers cannot report such unlawful claims to credit bureaus. Please immediately adjust this account to reflect in-network cost-sharing, recall any collection assignments, and ensure no credit reporting occurs. Sincerely, [CLIENT FULL NAME] Sent via Certified Mail, Return Receipt Requested: [LETTER CERTIFIED NUMBER]