No Surprises Act Dispute: When Your Bill Is $400+ Over the Estimate

If you were uninsured — or chose not to use your insurance — federal law required your provider to give you a good faith estimate before scheduled care. When the final bill for a provider comes in at least $400 above that provider’s estimate, you can challenge it through the federal patient–provider dispute resolution (PPDR) process: an independent third party reviews the bill and sets the amount you owe. This page is the plain-English version of the CMS rules.

Eligibility checklist — you need every box

• You did not have health insurance for this care, or you told the provider in advance you would not use it (self-pay)
• The care happened on or after January 1, 2022
• You received a written good faith estimate from the provider (you cannot use this process without one)
• The bill from that provider is $400 or more above the estimate for that same provider — the test is per provider, not on the combined total
• Your initial bill is dated within the last 120 calendar days

Covered by Medicare, Medicaid, or another federal program instead? Those programs have their own appeal routes; this process is not for you.

How the process works

1. Try the provider first (optional but often faster). Show them the estimate and the bill side by side and ask them to match the estimate or explain the difference. Providers can and do adjust bills at this stage.
2. Start the federal dispute within 120 calendar days of the initial bill — through the federal dispute portal, by fax, or by mail, using the CMS initiation form. Do not let this deadline pass while you negotiate informally.
3. Pay the $25 administrative fee to the selected dispute resolution entity. The process does not start until the fee is paid. If the decision goes your way, the $25 is deducted from what you owe.
4. The dispute resolution entity reviews your estimate, your bill, and the provider’s explanation (for example, unforeseen complications that genuinely raised the cost).
5. You get a determination. If the reviewer agrees with you, you pay the estimate amount. If they agree with the provider, you owe the higher amount. Either way, your costs cannot increase for having disputed — and while the dispute runs, you and the provider may still settle between yourselves; if you do, the provider must notify the dispute entity within 3 days of the settlement.

Worked example

An uninsured patient received a good faith estimate of $1,200 for an imaging study. The bill arrived at $1,890 — $690 over the estimate, from the same facility. She started the PPDR process on day 40, paid the $25 fee, and submitted her estimate and bill. The facility could not document an unforeseen circumstance justifying the increase. Determination: she owed the estimate amount — a $690 reduction, minus the $25 fee credit.

Before you file: gather these

• Your written good faith estimate
• The bill (initial bill — note its date; your 120 days run from it)
• Any documentation about what changed during care, if anything
• Records of any negotiation attempts with the provider

No estimate, or an insured surprise bill instead?

This process needs an estimate. Different problem, different page:

• Insured and got an out-of-network emergency bill, or an out-of-network bill at an in-network facility: that is balance billing, generally prohibited — start with Disputing medical charges (error #8) and your plan’s appeal route.
• Insurer denied your claim: Health insurance denial appeal guide.
• Not sure which route is yours: How to dispute a medical bill routes by situation.
• Questions or a complaint about a surprise bill: the federal No Surprises Help Desk, 1-800-985-3059 (free).

Frequently asked questions

How do I pay the dispute administrative fee? The $25 non-refundable fee is paid to the selected dispute resolution entity — CMS notes it can be paid online by credit card, PayPal, or Venmo. The process does not begin until it is paid; if you win, the $25 is deducted from the amount you owe the provider.

What happens if the agency reviewing my dispute agrees with me — or disagrees? If the reviewer agrees with you, you pay the amount on your good faith estimate. If the reviewer agrees with the provider, you pay the higher billed amount. Either way, the provider cannot raise your bill because you disputed it (CMS).

Can I settle with my provider before the dispute process ends? Yes. You and the provider can agree on a payment amount at any point during the process. If you settle, the provider must notify the dispute resolution entity as soon as possible, and no later than 3 days after the settlement (CMS).

How long do I have to start a dispute? 120 calendar days from the date on your initial bill. This is the deadline patients most often miss by negotiating informally first — file in time, and keep negotiating in parallel if you wish.

Sources: CMS, “Dispute a medical bill,” “Know your medical bill rights when not using insurance,” and the Patient–Provider Dispute Resolution requirements (45 CFR 149.620). Educational information, not legal advice. Reviewed 2026-10-22.