Inform Ambetter of a Balance Bill

After receiving medical care, you may get a bill from your provider. Providers can only bill you for your share of the cost of covered services. This includes your deductible, copayment, cost sharing percentage and any unauthorized or non-covered services. If you receive a bill from a provider that does not reflect your cost share as listed in your Summary of Benefits or your Major Medical Expense Policy, please contact us right away. You should not be balance billed for covered services beyond your responsibility for dates of service on or after January 1, 2020.

Please complete this form if you have received a bill from a provider for any amount greater than your copayment, coinsurance, or deductible. If you have any questions or if you would like additional assistance, please contact Ambetter Member Services at 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) from 8 a.m. to 8 p.m. CST.

Member ID *

Date of Service *

Provider Name *

Please tell us about the bill you received: *

The “Inform Ambetter of a Balance Bill” form will send your message to Ambetter from Superior HealthPlan as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Ambetter through email, you accept the risks associated thereof. Ambetter does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your protected health information (PHI), please send us a message through the Secure Member Portal or Provider Portal, or you can call us at the Member Services number on the back of your Ambetter ID card to speak directly to a customer service representative.

By communicating with Ambetter via email, you give consent to receive information from Ambetter, which may contain PHI, to your email address. This consent is not required. Communication via email is not as secure as communicating via our secure member portal. If you do not want to receive email responses, please let us know.