Sample: a 3-day hospital stay, $23,499 billed

Jordan Avery
[Your mailing address]
[Your phone or email]

November 12, 2026

Attn: Patient Financial Services / Billing Department
Riverbend Regional Medical Center
Patient Financial Services, 4100 Riverbend Pkwy, Springfield, OH 45501

Re: Patient Jordan Avery
Account number: RB-20914-3387
Date(s) of service: September 14, 2026 to September 16, 2026

To whom it may concern:

Please send me a complete itemized statement for the account above. For every charge, please include:

  1. The date of service
  2. The CPT or HCPCS code and the revenue code
  3. A plain description of the item or service
  4. The number of units and the charge per unit
  5. All payments, insurance adjustments and discounts applied

I am also requesting copies of my billing records under my HIPAA right of access (45 CFR §164.524), which covers billing records maintained by or for a covered entity. Please provide them within 30 days.

While I review the itemized bill, please place this account on hold and do not refer it to a collection agency or report it to any credit bureau. Please also send me a copy of your financial assistance policy and application.

You can send the statement to the address above or by email.

Sincerely,


Jordan Avery

Jordan Avery
[Your mailing address]
[Your phone or email]

November 12, 2026

Attn: Billing Disputes / Patient Financial Services
Riverbend Regional Medical Center
Patient Financial Services, 4100 Riverbend Pkwy, Springfield, OH 45501

Re: Patient Jordan Avery
Account number: RB-20914-3387
Date(s) of service: September 14, 2026 to September 16, 2026

To whom it may concern:

I am writing to dispute charges on the account above. I have reviewed the statement dated October 2, 2026 and found the following problems:

  1. Room charge on your discharge day.
     Remove the room-and-board charge dated 2026-09-16 ($3,150.00), the date of discharge.
     (Basis: Medicare Claims Processing Manual, Ch. 3 (day of discharge not counted as an inpatient day))

  2. Charged more than the hospital's own posted price for 71275.
     Re-price code 71275 to your published price of $1,890.00 per unit (difference $3,090.00).
     (Basis: Hospital Price Transparency rule, 45 CFR Part 180)

  3. Charged more than the hospital's own posted price for 80053.
     Re-price code 80053 to your published price of $84.00 per unit (difference $228.00).
     (Basis: Hospital Price Transparency rule, 45 CFR Part 180)

  4. Billed separately but already included in the IV push.
     Remove the separately billed component 36000 on 2026-09-14 ($148.00), which is included in 96374.
     (Basis: CMS National Correct Coding Initiative (NCCI) procedure-to-procedure edits)

  5. Billed separately but already included in the comprehensive metabolic panel.
     Remove the separately billed components 82565, 84132 on 2026-09-14 ($122.00), which are included in 80053.
     (Basis: CMS National Correct Coding Initiative (NCCI) procedure-to-procedure edits)

  6. Billed separately but already included in the complete ECG.
     Remove the separately billed component 93010 on 2026-09-14 ($96.00), which is included in 93000.
     (Basis: CMS National Correct Coding Initiative (NCCI) procedure-to-procedure edits)

  7. Line total doesn't match quantity × price.
     Correct the line total for J2405 to $178.00 (it is billed at $267.00).

  8. Charged 2 times: Venipuncture, routine.
     Remove the duplicate code 36415 "Venipuncture, routine" charges dated 2026-09-14 (2 entries of $42.00), or show documentation that each was separately provided.

  9. Highest-level visit code (99285).
     Provide the medical-record documentation supporting visit level 99285 ($2,840.00), or re-code it to the level the record supports.
     (Basis: CMS E/M documentation guidelines)

  10. Charged 2 times: Troponin, quantitative.
     Remove the duplicate code 84484 "Troponin, quantitative" charges dated 2026-09-14 (2 entries of $168.00), or show documentation that each was separately provided.

  11. Routine supplies billed one by one (3).
     Remove the separately billed routine supplies (Admission kit; Gloves, non-sterile; Pulse oximeter probe; $152.00 total) or show they are not covered by the room or procedure charge.
     (Basis: CMS Provider Reimbursement Manual §2202.6 (routine services include routine supplies))

  12. Over-the-counter medicine at $28.50 a dose.
     Justify or reduce the charge for Acetaminophen 500 mg tablet ($57.00).

  13. Over-the-counter medicine at $18.00 a dose.
     Justify or reduce the charge for Docusate sodium 100 mg capsule ($36.00).

The charges in question total about $10,125.00. 
Please review each item, correct the account, and send me a revised statement. If you believe any charge is correct, please send the medical-record documentation that supports it.

Please place this account on hold while the dispute is open, and do not refer it to collections or report it to a credit bureau until it is resolved. Please respond in writing within 30 days.

Sincerely,

Jordan Avery

Jordan Avery
[Your mailing address]
[Your phone or email]

November 12, 2026

Attn: Financial Assistance / Financial Counseling
Riverbend Regional Medical Center
Patient Financial Services, 4100 Riverbend Pkwy, Springfield, OH 45501

Re: Patient Jordan Avery
Account number: RB-20914-3387
Date(s) of service: September 14, 2026 to September 16, 2026

To whom it may concern:

I am applying for financial assistance (charity care) for the account above, and I ask that you send me your financial assistance policy, the plain-language summary, and the application form if this letter alone is not sufficient.

My household has 3 people, and our annual household income is $52,000.00, about 195% of the federal poverty guideline. I can provide proof of income on request.

As a tax-exempt hospital, you are required under Internal Revenue Code §501(r) to maintain and widely publicize a financial assistance policy, to limit charges for eligible patients to no more than the amounts generally billed to insured patients, and to make reasonable efforts to determine eligibility before taking any extraordinary collection action (26 CFR §1.501(r)-4 through -6).

Please suspend all collection activity on this account while my application is reviewed, and apply any assistance retroactively, including refunding any amount I have already paid above what I owe under your policy.

Please send your decision in writing.

Sincerely,


Jordan Avery