What's in a pack

You review and send these letters yourself. BillRebuttal does not contact your provider, insurer or collector, and no advocate negotiates for you. What's below was generated from the bill lines you reviewed on BillRebuttal. Check every line against your actual bill and fix anything that's wrong before sending. Fill in the [bracketed] fields. Keep copies and send by a method you can track. What the flags mean: - "Possible duplicate" / "Possible unbundling": the bill pattern suggests a billing error. The provider may confirm it is correct. - "Above Medicare reference": the price is higher than what Medicare pays. That is not by itself an error or an unlawful price, and it doesn't mean you are owed that difference. - "Ask for documentation": a question, not an accusation. Results are not guaranteed. Not legal, medical or financial advice. BillRebuttal is not a law firm.

[Your name] [Address] [Date] To the Billing Department, [Provider name] Re: Account [account number], date(s) of service [dates] I am requesting a review of the charges listed below. Please send me a fully itemized bill showing CPT/HCPCS codes, dates of service, units and modifiers for every line. Please also tell me whether this account can be placed on hold from collection activity while the review is pending. 1. line 1,6, service date 2026-03-02, code 85025, charged $68.00. This charge appears more than once with the same date, units, modifiers and amount. Please confirm whether it was billed twice in error and correct it, or tell me why the service was provided more than once. 2. Panel 80053 on 2026-03-02 (lines 3). Component tests of this panel appear to be billed in addition to the panel. Please confirm whether they were part of the same draw and, if so, remove the separate charges. 3. service date 2026-03-02, code 85025, charged $68.00. For reference, the Medicare national amount for this service (Clinical Lab Fee Schedule national limit) is $7.77. I am not saying this charge is an error. I am asking for your self-pay or prompt-pay price for this service, a review under your financial assistance policy, or an explanation of the charge. 4. service date 2026-03-02, code 80053, charged $212.00. For reference, the Medicare national amount for this service (Clinical Lab Fee Schedule national limit) is $10.56. I am not saying this charge is an error. I am asking for your self-pay or prompt-pay price for this service, a review under your financial assistance policy, or an explanation of the charge. 5. service date 2026-03-02, code 36415, charged $38.00. For reference, the Medicare national amount for this service (Clinical Lab Fee Schedule national limit) is $9.34. I am not saying this charge is an error. I am asking for your self-pay or prompt-pay price for this service, a review under your financial assistance policy, or an explanation of the charge. 6. service date 2026-03-02, code 99285, charged $3250.00. For reference, the Medicare national amount for this service (Hospital outpatient (OPPS) APC 5025 facility rate) is $608.43. I am not saying this charge is an error. I am asking for your self-pay or prompt-pay price for this service, a review under your financial assistance policy, or an explanation of the charge. 7. Code 99285. Please send the documentation that supports the level of service billed. Please respond in writing within 30 days. Sincerely, [Your name]

1. "I'm calling about account [#]. I'd like to request a review of some charges and ask whether the account can be put on hold while it's reviewed." 2. "Can you send a fully itemized bill with CPT codes, dates, units and modifiers?" 3. Go through each item: 85025, 80053, 36415, 99285. Ask whether each one is correct and why. 4. "What is your self-pay or prompt-pay price? Do you have a financial assistance policy I can apply under?" 5. Write down the representative's name, the date and a reference number.

I asked for a review of charges on account [#] on [date] and have not received a written response. Please confirm the status of the review and send the itemized bill within 14 days.

This is my second follow-up about my request of [date]. If I don't receive a response, I may contact my state attorney general's consumer protection office or my state insurance department, and, if the bill involves No Surprises Act protections, the CMS No Surprises Help Desk (1-800-985-3059).

To [collection agency] Re: Account [#] Under the Fair Debt Collection Practices Act (15 U.S.C. 1692g), I dispute this debt and request validation, including the name of the original creditor and an itemized statement from the original provider. Please do not report this disputed debt to credit bureaus while it is in dispute. Note for you (not part of the letter): the three national credit bureaus have said they don't include paid medical collections or medical collections under $500 in credit reports. Some states have stronger rules.

To [insurer], Appeals Re: Member ID [#], claim for date of service [date] I request an internal appeal of this claim. Please review the following items: 1. line 1,6, service date 2026-03-02, code 85025, charged $68.00. This charge appears more than once with the same date, units, modifiers and amount. Please confirm whether it was billed twice in error and correct it, or tell me why the service was provided more than once. 2. Panel 80053 on 2026-03-02 (lines 3). Component tests of this panel appear to be billed in addition to the panel. Please confirm whether they were part of the same draw and, if so, remove the separate charges. 3. service date 2026-03-02, code 85025, charged $68.00. For reference, the Medicare national amount for this service (Clinical Lab Fee Schedule national limit) is $7.77. I am not saying this charge is an error. I am asking for your self-pay or prompt-pay price for this service, a review under your financial assistance policy, or an explanation of the charge. 4. service date 2026-03-02, code 80053, charged $212.00. For reference, the Medicare national amount for this service (Clinical Lab Fee Schedule national limit) is $10.56. I am not saying this charge is an error. I am asking for your self-pay or prompt-pay price for this service, a review under your financial assistance policy, or an explanation of the charge. 5. service date 2026-03-02, code 36415, charged $38.00. For reference, the Medicare national amount for this service (Clinical Lab Fee Schedule national limit) is $9.34. I am not saying this charge is an error. I am asking for your self-pay or prompt-pay price for this service, a review under your financial assistance policy, or an explanation of the charge. 6. service date 2026-03-02, code 99285, charged $3250.00. For reference, the Medicare national amount for this service (Hospital outpatient (OPPS) APC 5025 facility rate) is $608.43. I am not saying this charge is an error. I am asking for your self-pay or prompt-pay price for this service, a review under your financial assistance policy, or an explanation of the charge. 7. Code 99285. Please send the documentation that supports the level of service billed. Please send me the claim file and the criteria used for your decision. If the denial is upheld, I request information on external review.

To [hospital], Financial Assistance Re: Account [#] Please send me your Financial Assistance Policy, the plain-language summary, and the application. If I apply, please suspend extraordinary collection actions while the application is pending, as required for nonprofit hospitals under IRS rules (26 CFR 1.501(r)-6). Household size: ___ Annual income: ___ Free help applying: Dollar For (dollarfor.org), not affiliated with BillRebuttal.