Good Faith Estimate requirements for providers

Since January 1, 2022, the No Surprises Act has required health care providers to give uninsured and self-pay patients a Good Faith Estimate. The detailed rules are in 45 CFR 149.610. Here they are in plain English.

Who must give one

Any health care provider or facility that schedules items or services for an uninsured or self-pay individual, or receives a request for an estimate. That includes therapists, counselors, psychologists and other mental health clinicians in private practice.

Self-pay includes insured people who don't seek to have a claim submitted to their plan. See Good Faith Estimates for insured patients for the grey areas.

Deadlines

• Service scheduled at least 3 business days ahead: estimate within 1 business day of scheduling.
• Service scheduled at least 10 business days ahead: within 3 business days of scheduling.
• Patient asks for an estimate: within 3 business days of the request.
• If the scope changes: a new estimate no later than 1 business day before the service.

You must also tell self-pay patients, in writing and orally, that they can get an estimate, and post the notice in your office and on your website.

What the estimate must contain

1. Patient name and date of birth.
2. Description of the primary item or service, and the scheduled date if there is one.
3. Itemized list of expected items and services for the period of care.
4. Applicable diagnosis codes, expected service codes and expected charges for each item.
5. Name, NPI and tax ID of each provider or facility, and the state and location where services will be furnished.
6. A list of items or services that will need to be scheduled separately, with instructions for getting their estimates.
7. A disclaimer that other recommended services may need to be scheduled separately.
8. A disclaimer that this is only an estimate and actual charges may differ.
9. A disclaimer about the right to the patient-provider dispute resolution process, with instructions, and that starting it won't affect the quality of care.
10. A disclaimer that the estimate is not a contract and doesn't oblige the patient to receive the services.

Recurring care such as weekly therapy

One estimate can cover recurring services if it clearly states the expected scope, such as frequency and total number of sessions. It can cover no more than 12 months. If care continues, issue a new one.

Record keeping

Estimates are part of the patient's medical record. You must give a patient a copy of any estimate issued in the last 6 years when they ask.

Disputes

If the bill is at least $400 more than the estimate, the patient can start patient-provider dispute resolution within 120 calendar days of the bill, for a $25 fee. You may not take collection action on the disputed amount while the dispute is pending.

What is not enforced yet

• Co-provider estimates. When several providers are involved, the convening provider is supposed to collect and include everyone's charges. Enforcement is deferred until further rulemaking; until then each provider can issue their own.
• Estimates for insured patients sent to health plans (Advanced Explanation of Benefits). Also deferred, with no enforcement date set as of October 2026.

Questions