How to get help with a surprise bill from a health care provider

Mediation for a health insurance claim

Read these instructions if you got medical services or supplies before January 1, 2018.

We can help you with your surprise bill if:

• You have health coverage through an insured preferred provider organization (PPO) or the Employees Retirement System of Texas.
• The amount of the bill is more than $500, not including copays, deductibles, and coinsurance.
• You didn’t sign an estimate that shows a cost of services that is the same or less than your bill.
• You were billed for medical services or supplies:
  • At a hospital that is in your health plan’s network.
    and
  • By one of the following hospital-based providers who isn’t in your health plan’s network:
    • Radiologist
    • Anesthesiologist
    • Pathologist
    • Emergency department physician
    • Neonatologist
    • Assistant surgeon

If you meet the above rules:

1. Get these three documents together:
   • A copy of the front of your health insurance ID card.
   • A copy of your Explanation of Benefits (EOB) form. Your insurance company sends this form to you after you get health care services.
   • A copy of the doctor or provider’s bill.
2. Fill out the form and attach the documents listed in step A:
   • English: Get help with a surprise bill you got from a health care provider
   • Espanol: Obtenga ayuda si recibió una factura sorpresa de un proveedor de servicios médicos

Learn more about how this process works:

Visit our How Mediation Works web page.

If you aren’t able to get help with a surprise bill:

You can file a complaint about your health insurance. To learn more, go to our Insurance Complaint Process web page.