Surprise Medical Bill? California Demand Letter for Out-of-Network & Balance Billing

DISPUTE OF SURPRISE MEDICAL BILL - DEMAND FOR CORRECTION [Your Name] [Your Address] [City, CA ZIP] [Phone] [Email] [Date] VIA CERTIFIED MAIL, RETURN RECEIPT REQUESTED [Provider/Hospital Name] [Billing Department Address] [City, State ZIP] Re: Dispute of Surprise Medical Bill - Violation of California/Federal Law Patient: [Your Name] Date of Service: [Date of Service] Account/Invoice Number: [Account Number] Amount Disputed: $[Balance Bill Amount] Dear Billing Department: I am writing to formally dispute the above-referenced bill as an illegal surprise medical bill under California Health & Safety Code Section 1371.9 (AB 72) and/or the federal No Surprises Act (Public Law 116-260). FACTS: 1. On [Date of Service], I received [describe services - e.g., "emergency medical treatment" or "surgical services"] at [Hospital/Facility Name]. 2. [Choose applicable scenario:] [ ] This was an EMERGENCY service, and I had no ability to choose my providers. [ ] This was a scheduled procedure at an IN-NETWORK facility ([Hospital Name] is in-network with my insurance). [ ] I did NOT consent in writing to receive out-of-network services. 3. I have received a bill from [Provider Name] for $[Amount], which represents balance billing/out-of-network charges beyond what my insurance paid. 4. My health insurance information: Insurance Company: [Insurance Company Name] Member ID: [Member ID] Group Number: [Group Number] LEGAL VIOLATIONS: This bill violates applicable law because: [Check all that apply:] [ ] EMERGENCY SERVICES: Under California Health & Safety Code 1371.30-1371.31 and the federal No Surprises Act, patients CANNOT be balance billed for emergency services. I am only responsible for in-network cost-sharing. [ ] AB 72 VIOLATION: Under California Health & Safety Code 1371.9, when I receive services at an in-network facility from an out-of-network provider I did not choose, I can only be billed my in-network cost-sharing amount. The provider must seek additional payment from my insurer, not me. [ ] NO SURPRISES ACT VIOLATION: Under the federal No Surprises Act (effective January 1, 2022), I am protected from balance billing for non-emergency services provided by out-of-network providers at in-network facilities. [ ] NO VALID CONSENT: I never signed a consent form at least 72 hours in advance acknowledging the provider was out-of-network and agreeing to pay out-of-network rates, as required for any exception to these protections. DEMAND: I demand that you immediately: 1. REMOVE the balance billing amount of $[Amount] from my account; 2. Correct my account to reflect only my in-network cost-sharing obligation (if any); 3. [If already paid:] REFUND the amount I have already paid toward this illegal balance bill: $[Amount Paid]; 4. Confirm in writing that this matter is resolved and no collection action will be taken; 5. If this bill has been reported to credit bureaus, immediately request deletion of this tradeline. Please respond in writing within thirty (30) days. If this matter is not resolved, I will: - File a complaint with the California Department of Managed Health Care (DMHC) or Department of Insurance (CDI); - File a complaint under the federal No Surprises Act complaint process; - Pursue all available legal remedies, including recovery of any payments made plus applicable penalties. I have enclosed copies of my Explanation of Benefits, the disputed bill, and proof of the facility's in-network status with my insurer. Please contact me at [Phone/Email] to resolve this matter. Sincerely, _______________________________ [Your Signature] [Your Printed Name] Enclosures: - Explanation of Benefits (EOB) from insurance - Copy of disputed bill - Proof of in-network facility status - [Any payments made - receipts/bank statements] - [Emergency room records, if applicable] cc: [Your Insurance Company] California Department of Managed Health Care (if filing complaint)