A Denial or Unexpected Bill: What to Do Next

Start with the document you received. A bill, an insurance decision and an estimate can lead to different next steps. Find the service, the reason and any deadline. Keep copies so you do not have to explain the whole issue on every call.

For: U.S. adults sorting out a treatment bill or coverage denial, and people they choose to help · 3 PDF pages

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Separate the Documents

Sources: [2]

When the health plan denied coverage

An internal appeal asks the insurer to reconsider. External review uses an independent third party when the decision qualifies. HealthCare.gov describes these routes for health-plan decisions. Follow the notice and your plan’s process, including any urgent-review option. Do not copy a deadline from a different plan or from the separate self-pay dispute below. Ask the treating clinician whether supporting medical information is needed. If you have Medicare, use its appeal instructions. For Medicaid, contact your plan or state agency about the route on your notice.

Sources: [1] [3] [4]

Gather These Before the Call

• The notice or bill, service date, provider name, claim or reference number and the stated reason.
• Every deadline on the notice or bill. Ask what must be submitted or received by that date, where to send it and how to prove receipt.
• The estimate, prior authorization, referral or coverage answer you already received, if relevant.
• The correction or explanation you are asking for. Ask the treating clinician whether supporting information is needed.

Sources: [3]

When the problem is the bill itself

• If you did not use insurance: CMS has a separate patient-provider dispute process for some bills at least $400 above that provider’s written good faith estimate. Its listed criteria include telling the provider before care that insurance would not be used, care on or after January 1, 2022, an estimate received at least three days before the scheduled appointment, and an initial bill dated within the last 120 calendar days. There is a $25 nonrefundable filing fee. Check the CMS criteria or call 1-800-985-3059 before assuming you qualify. This is not an insurance appeal.
• If you used private insurance: federal surprise-billing protections apply in specified settings, including most emergency care, certain out-of-network services at in-network hospitals, hospital outpatient departments or ambulatory surgical centers, and air ambulances. They do not cover every unexpected treatment bill. Ground ambulances and other settings have different rules or exceptions. Use the CMS guidance to check your situation.
• If you cannot afford the bill: ask the billing office for its financial-assistance policy, eligibility rules, application, deadline and a contact for help. Nonprofit hospitals must assist eligible patients who cannot afford care. Other facilities may offer help, but do not assume every rehab program has the same obligation. Ask about payment arrangements if assistance is unavailable.
• Keep the questions separate: request correction of a billing error, pursue the applicable coverage review, and ask about assistance as needed. Ask what happens to the bill while each request is pending. Do not assume a call, a complaint or an assistance request pauses payment, collection or appeal deadlines.

Sources: [5] [6] [7]

Your Review Record

Decision, reason and deadline

Reason, amount if relevant, deadline and where it came from. Keep each process separate.

People contacted and their answers

Date, department, name, reference number and what they agreed to do.

Documents and next action

What, to whom, by when, proof of receipt, who follows up and any unresolved question.

Find the right help

• HealthCare.gov: internal and external appeals
• Paying for rehab
• CMS: find an action plan for your medical bill

Keep notes private. Use approved channels to share documents. This guide does not determine coverage or legal rights. Check source details.