Sample only: a fictional hospital bill with planted errors and an EOB. Check your own bill.

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SAMPLE COMMUNITY HOSPITAL (a nonprofit 501(c)(3) hospital) - see our Financial Assistance Policy
Statement date: 03/20/2026
Admit date: 03/02/2026
Discharge date: 03/04/2026
Account: SAMPLE-0001   Patient: Pat Sample (fictional)
03/02/2026 0450 99285 ER VISIT LEVEL 5                  1  $2,850.00
03/02/2026 0450 99284 ER VISIT LEVEL 4                  1  $1,900.00
03/02/2026 0300 80053 COMPREHENSIVE METABOLIC PANEL     1    $412.00
03/02/2026 0300 80048 BASIC METABOLIC PANEL             1    $298.00
03/02/2026 0300 85025 CBC W AUTO DIFF                   1    $187.00
03/02/2026 0300 85025 CBC W AUTO DIFF                   1    $187.00
03/02/2026 0300 36415 VENIPUNCTURE                      1     $45.00
03/02/2026 0730 93000 ECG COMPLETE                      1    $310.00
03/02/2026 0730 93010 ECG INTERPRETATION                1    $120.00
03/02/2026 0120 ROOM AND BOARD SEMI-PRIVATE             3  $5,400.00
03/03/2026 0960 99214 OFFICE VISIT FOLLOW-UP            1    $420.00
Emergency physician: Sample ER Physicians Group (out-of-network)
Total charges: $12,129.00
Insurance paid: $6,100.00
Amount due: $3,400.00

EXPLANATION OF BENEFITS - SAMPLE HEALTH PLAN
Claim for services 03/02/2026 at Sample Community Hospital (in-network facility)
Emergency physician services: out-of-network provider, emergency
Patient responsibility: $1,250.00

Your bill review

Read 11 charge lines via sample text. State: TX.

Likely errors: $4,305.00 in charges to question

Your bill asks for $2,150.00 more than your EOB says you owe.

Issue	Code	Date	Amount	Why	Confidence
duplicate	85025	2026-03-02	$187.00	85025 billed twice on 2026-03-02 for the same amount	likely
unbundling	80048	2026-03-02	$298.00	80048 is part of 80053 billed the same day (NCCI procedure-to-procedure edit)	likely
unbundling	93010	2026-03-02	$120.00	93010 is part of 93000 billed the same day (NCCI procedure-to-procedure edit)	likely
unbundling	99284	2026-03-02	$1,900.00	two emergency visit levels (99285 and 99284) billed the same day; only one is allowed	likely
upcoding check	99285	2026-03-02	-	99285 is the highest visit level; ask for the record that supports that level of medical decision making	check
discharge day room	0120	2026-03-04	$1,800.00	3 room days billed for 2 nights (admit 2026-03-02, discharge 2026-03-04); the discharge day is not a room day	likely
eob mismatch			$2,150.00	the bill asks for $3,400.00 but my insurer's EOB says my responsibility is $1,250.00	likely

Fair price

Medicare 2026 rate and the typical commercial price (RAND: 1.84x Medicare for clinician services). UNKNOWN means we have not verified a benchmark for that code: look it up with the CMS fee schedule tool, FAIR Health or the hospital's own price file. CPT is a registered trademark of the American Medical Association; CPT codes are copyright AMA. We show only the code numbers printed on your bill, your bill's own descriptions, a broad category in our own words and CMS Medicare payment amounts; we do not provide CPT descriptions.

Code	Category (our words)	Your bill says	Billed	Medicare	Typical commercial
99285	Visit with a doctor or other clinician (office, hospital or emergency)	ER VISIT LEVEL 5	$2,850.00	$171.35	$315.28	Ask for a lower price
99284	Visit with a doctor or other clinician (office, hospital or emergency)	ER VISIT LEVEL 4	$1,900.00	$118.24	$217.56	Ask for a lower price
80053	Lab test or pathology	COMPREHENSIVE METABOLIC PANEL	$412.00	$10.56	$19.43	Ask for a lower price
80048	Lab test or pathology	BASIC METABOLIC PANEL	$298.00	$8.46	$15.57	Ask for a lower price
85025	Lab test or pathology	CBC W AUTO DIFF	$187.00	$7.77	$14.30	Ask for a lower price
85025	Lab test or pathology	CBC W AUTO DIFF	$187.00	$7.77	$14.30	Ask for a lower price
36415	Surgery or procedure	VENIPUNCTURE	$45.00	$9.34	$17.19	Ask for a lower price
93000	Medical test, therapy or other service	ECG COMPLETE	$310.00	$15.36	$28.26	Ask for a lower price
93010	Medical test, therapy or other service	ECG INTERPRETATION	$120.00	$8.35	$15.36	Ask for a lower price
REV0120	Hospital department charge (revenue code)	ROOM AND BOARD SEMI-PRIVATE	$5,400.00	UNKNOWN	UNKNOWN
99214	Visit with a doctor or other clinician (office, hospital or emergency)	OFFICE VISIT FOLLOW-UP	$420.00	$135.61	$249.52	Ask for a lower price

Protections that apply

HIPAA right of access (billing + medical records): Get the billing and medical records that support each charge. Deadline: 2026-12-10 (provider's 30-day deadline if you send today) (45 CFR 164.524: copy within 30 days (one 30-day extension); billing records are in the designated record set (164.501); reasonable cost-based fee only source)
No Surprises Act balance-billing protection: Emergency or out-of-network clinician at an in-network facility: you can only owe in-network cost sharing. Deadline: complain any time: 1-800-985-3059 (42 USC 300gg-111, 300gg-131/-132; 45 CFR 149.410-.440: emergency care and out-of-network clinicians at in-network facilities may bill only in-network cost sharing. Help desk 1-800-985-3059 source)
Nonprofit hospital financial assistance (incl. retroactive refunds): Nonprofit hospital: apply for financial assistance; payments above the assistance amount must be refunded. Deadline: 2026-11-15 (240 days from the first post-discharge bill) (26 CFR 1.501(r)-4 (FAP), -5 (charges limited to AGB), -6 (240-day application period, ECAs suspended, refund of payments above the FAP amount) source)
Prompt-pay / self-pay discount request: Bill is current: ask for the self-pay / prompt-pay discount before paying. (Hospital self-pay policy (no general statute; uninsured-discount laws in some states) source)

Your letters (you send them)

Error dispute

2026-11-10

To: [provider name]
Re: account [account number]
From: [Your name]

I am disputing the following charges after reviewing my itemized bill:
- duplicate: 85025 billed twice on 2026-03-02 for the same amount ($187.00)
- unbundling: 80048 is part of 80053 billed the same day (NCCI procedure-to-procedure edit) ($298.00)
- unbundling: 93010 is part of 93000 billed the same day (NCCI procedure-to-procedure edit) ($120.00)
- unbundling: two emergency visit levels (99285 and 99284) billed the same day; only one is allowed ($1,900.00)
- discharge day room: 3 room days billed for 2 nights (admit 2026-03-02, discharge 2026-03-04); the discharge day is not a room day ($1,800.00)
- eob mismatch: the bill asks for $3,400.00 but my insurer's EOB says my responsibility is $1,250.00 ($2,150.00)

Please correct these charges, send a corrected statement, and hold the account from collection while you review.

I also ask for the documentation supporting the visit level for: 99285.

Please reply in writing.

[Your name]

This is general information and a letter you send yourself, not legal advice. BillAdvocate does not contact anyone for you.

Hipaa access

2026-11-10

To: [provider name]
Re: account [account number]
From: [Your name]

Under 45 CFR 164.524 I request a copy of my designated record set for the dates of service on this account, including billing records, itemized charges and the medical records supporting each charge. Please send it electronically if possible within 30 days and tell me any cost-based fee in advance.

Please reply in writing.

[Your name]

This is general information and a letter you send yourself, not legal advice. BillAdvocate does not contact anyone for you.

Nsa balance bill

2026-11-10

To: [provider name]
Re: account [account number]
From: [Your name]

This bill charges me more than my in-network cost sharing for care protected by the No Surprises Act (42 USC 300gg-131/-132; 45 CFR 149.410-.440). Please correct the bill to the in-network cost-sharing amount shown on my EOB and refund any excess. I am also reporting this to the No Surprises Help Desk (1-800-985-3059).

Please reply in writing.

[Your name]

This is general information and a letter you send yourself, not legal advice. BillAdvocate does not contact anyone for you.

Fap application

2026-11-10

To: [provider name]
Re: account [account number]
From: [Your name]

Please treat this as my application for financial assistance under your Financial Assistance Policy (26 CFR 1.501(r)-4 to -6). Please send the application form and list of documents, suspend any extraordinary collection actions while it is pending, and refund any amount I paid above what I owe once I am found eligible. My household income is about 109% of the federal poverty guideline.

Please reply in writing.

[Your name]

This is general information and a letter you send yourself, not legal advice. BillAdvocate does not contact anyone for you.

Prompt pay

2026-11-10

To: [provider name]
Re: account [account number]
From: [Your name]

I am ready to pay this bill promptly. What self-pay or prompt-payment discount can you apply if I pay the balance in full within the next 30 days? Please confirm the discounted amount in writing.

Please reply in writing.

[Your name]

This is general information and a letter you send yourself, not legal advice. BillAdvocate does not contact anyone for you.

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They replied? Draft my answer

This is general information and a letter you send yourself, not legal advice. BillAdvocate does not contact anyone for you. BillAdvocate is not a law firm and is not your lawyer: letters are drafted by software (and, only if you ask, reworded by an AI service) from what you enter, and no lawyer has reviewed them. Check every fact, amount and date before you send, and talk to a lawyer or legal aid office if you are being sued or a deadline is close. These letters are not a substitute for the advice of an attorney.