Tip for NSA Dispute Resolution

The dispute only applies when the actual bill exceeds the GFE by $400 or more

Tip for NSA Dispute Resolution

A $25 administrative fee is required but is refunded if the dispute is resolved in your favor

Tip for NSA Dispute Resolution

The provider may offer to settle before the formal determination — negotiate if the offer is reasonable

Insurancehard

No Surprises Act Patient-Provider Dispute Resolution

NSA Dispute Resolution · CMS / HHS

Request for patient-provider dispute resolution when the actual charges substantially exceed the good faith estimate (by $400 or more). Initiates an independent resolution process.

Form Details

Total fields: 35
Auto-fillable: 18 (51%)
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Where to Submit This Form

🌐

File through the CMS dispute resolution portal

https://www.cms.gov/nosurprises/consumers/understanding-costs-in-advance

Initiate the patient-provider dispute resolution process online.

📬

Mail to the HHS dispute resolution entity

Address provided when initiating the dispute.

Filing Deadline

Within 120 days of receiving the bill that exceeds the Good Faith Estimate by $400 or more.

Required Attachments

📎 Copy of the original Good Faith Estimate
📎 Copy of the actual bill showing the higher amount
📎 Written explanation of the billing discrepancy
📎 Any relevant communications with the provider about the charges

Processing Time

The dispute resolution entity (Selected Dispute Resolution entity, or SDR entity) must make a determination within 30 business days of receiving all information.

What Happens Next

A dispute resolution entity will review the GFE and actual charges. If the entity sides with you, the provider must reduce the bill. A $25 administrative fee applies to initiate the dispute.

Tips for This Form

✓ The dispute only applies when the actual bill exceeds the GFE by $400 or more
✓ A $25 administrative fee is required but is refunded if the dispute is resolved in your favor
✓ The provider may offer to settle before the formal determination — negotiate if the offer is reasonable
✓ This process is separate from insurance appeals — it applies to uninsured and self-pay patients

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the CMS / HHS or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.