Ask your plan to reprocess a claim under the No Surprises Act
Ask your plan to reprocess a claim with the No Surprises Act protections, so you pay only in-network cost sharing that counts toward your in-network limits, and to treat the letter as an appeal if the claim stays denied.
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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) whose explanation of benefits (EOB) treats emergency care, care from an out-of-network clinician at an in-network facility, or an air ambulance flight as out of network or charges more than in-network cost sharing. You do not need a formal denial first: ask for reprocessing, and the letter asks the plan to treat it as an appeal if the claim stays denied. It is not for Medicare or Medicaid. Send a copy of the EOB with it.
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]
14 November 2026
[Name and address of the plan's appeals department, from your EOB or denial notice]
Re: Ask your plan to reprocess a claim under the No Surprises Act Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To the claims and appeals department:
I am asking [Name of the health plan] to reprocess claim [Claim or reference number] for [The care or drug that was denied] on [Date of the care] from [Doctor, hospital or pharmacy], with the protections of the federal No Surprises Act. My member identification (ID) number is [Member ID].
Your explanation of benefits (EOB) dated [Date of the explanation of benefits (EOB)] shows the following, which I believe is wrong: [What the EOB shows that looks wrong]
I believe the No Surprises Act may apply to this claim. If it applies, the plan must apply cost sharing no greater than in-network cost sharing, and must count that cost sharing toward my in-network deductible and in-network out-of-pocket maximum.
I ask that you: 1. Reprocess the claim with the No Surprises Act protections, if they apply. 2. Send me and the provider a corrected EOB that shows my cost sharing at the in-network level. 3. Count what I pay toward my in-network deductible and out-of-pocket maximum. 4. If you decide the Act does not apply, tell me in writing why, and treat this letter as my appeal of that decision. If the claim stays denied, or my cost sharing is not changed, I ask that you treat this letter as an appeal and send me the decision in writing with the reasons and my appeal rights.
Please call me at [A phone number where you can be reached] if you need anything.
Enclosures: 1. Copy of the explanation of benefits (EOB) 2. Copy of the provider's bill 3. Signed authorization, if someone is writing for the member and the plan requires one
Sincerely, [Your name]
Before you send it
Send it to the address on your EOB or denial notice for appeals or claim questions, by mail with tracking or through the plan's portal if it gives a confirmation. Call the number on your card, ask whether the plan received it, and write down the name, the date, the time and a reference number. Send a copy of the same request to the provider's billing office.
What to enclose
- Copy of the explanation of benefits (EOB)
- Copy of the provider's bill
- Signed authorization, if someone is writing for the member and the plan requires one
What happens next
- Keep your appeal deadline in view. A job-based plan must allow at least 180 days after you receive a denial notice to appeal, and the same minimum carries over to non-grandfathered individual coverage. Take the date from your notice, which controls.
- Do not pay the provider's balance until the plan reprocesses the claim. Ask the provider in writing to hold the account (“Tell the provider the No Surprises Act may apply to your bill”).
- A denial, or higher cost sharing, that turns on whether the No Surprises Act applies is an adverse benefit determination that can go to external review, including for grandfathered plans.
- The plan must decide whether services protected by the Act 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.
- 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 are helping someone else, the plan may require its own authorization form. See the letter "Name someone to act for you".
The rule behind this
- 45 CFR 149.110, emergency services
- 45 CFR 149.120, out-of-network providers at in-network facilities
- 45 CFR 149.420, balance billing and the notice-and-consent waiver
- 45 CFR 149.130, air ambulance services
- 45 CFR 149.410, balance billing in other cases
- 29 CFR 2590.715-2719, internal claims, appeals and external review
- 42 U.S.C. 300gg-115, provider directory accuracy
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.
- Denial reason
Not an emergency
Your plan says your emergency room visit was not a true emergency, so it denied the claim or paid it at a lower rate. The test is what your symptoms looked like to an ordinary person, not the final diagnosis.