No Surprises Act Complaint Form

Effective January 1, 2022, the federal No Surprises Act (NSA) provides protections for consumers under certain situations. The Department of Insurance has been tasked with assisting in the enforcement of this act by Centers for Medicare and Medicaid Services (CMS). Please fill out the form below if one of the following applies:

– Balance billing for an emergency claim.

– Charges from an out-of-network provider for services received at an in-network health care facility.

– Provider billing that is $400 or more over a written “good faith estimate.”

Once received, someone from the Idaho Department of Insurance will contact you.

Consumers, healthcare providers, and insurance companies can file a complaint regarding potential violations of the NSA.

If you are unsure whether your problem or question is related to the NSA, please contact Consumer Affairs at (208) 334-4250.

No Surprises Act Complaint Form

Full Name

Phone

Fax

Preferred method of contact:

Address

Street

Apt./Suite

City

State

Zip Code

Do you or did you have health insurance when you received the service in question?

Name of individual or company your complaint is against and contact information.

Who is your complaint against?

Name of Individual or Company

Phone

Fax

Street

Apt./Suite

City

State

Zip Code

Complaint Category

Date of service start or individual day

And/Through Date Selection

Date of service end or individual day

Have you reached out to your insurance provider or health care provider about this issue? Are they trying to assist you?

Please describe your concern or complaint.

Before submitting this form, please print this page for your records. A copy will also be sent to your email address entered.

Have more questions?

Contact the Consumer Affairs team: