Good faith estimate

Since January 1, 2022, the No Surprises Act requires providers to give uninsured and self-pay patients a written good faith estimate of expected charges before scheduled care. In a cash-pay practice, that is most patients. CMS publishes a model form; using it counts as good-faith compliance.

Who gets one

Patients without insurance, and insured patients who choose not to use their coverage for an item or service. People enrolled in a federal health care program (Medicare, Medicaid, TRICARE) are not eligible for a good faith estimate; other billing protections apply to them.¹ Whether a direct primary care or concierge membership fee itself needs an estimate is a question for your counsel; the guidance addresses items and services.

When it is due

• Within 1 business day of scheduling, when care is scheduled 3 or more business days ahead.
• Within 3 business days of scheduling, when care is scheduled 10 or more business days ahead.
• Within 3 business days of a request for cost information.¹²

What it must contain

The CMS model form lays out the required content:²

• Patient name, date of birth and contact details.
• The primary service or item, with the date if scheduled, and the diagnosis and diagnosis code if determined.
• An itemized list of the items and services expected for the period of care, grouped by provider or facility: the address where each is provided, the diagnosis code where it affects the estimate, the service or procedure code, the quantity and the expected cost.
• For each provider or facility: name, type, address, contact person, National Provider Identifier and Taxpayer Identification Number, and the total expected charges.
• The date of the estimate and a summary of the total estimated cost.
• The disclaimer explaining that the estimate is not a bill or a contract, and the patient's right to dispute a bill.

The dispute right

If a bill is at least $400 more than the estimate for any one provider or facility, the patient can start the federal patient-provider dispute resolution process within 120 calendar days of the date on the bill. While a dispute is open, the bill cannot go to collections and late fees stop accruing.²

The form

• CMS model notice, "Good Faith Estimate for Health Care Items and Services": cms.gov/files/document/good-faith-estimate-example.pdf. The copy read for this page carries OMB control number 0938-1433 with an expiration date of 11/2025, so download the current version from CMS before use.
• Consumer and provider information: cms.gov/nosurprises

1. Centers for Medicare & Medicaid Services. Good faith estimate and patient-provider dispute resolution process for uninsured or self-pay individuals. December 21, 2021. https://www.cms.gov/cciio/resources/regulations-and-guidance/downloads/good-faith-estimate-patient-provider-dispute-resolution-process-for-uninsured-or-self-pay-individuals.pdf
2. Centers for Medicare & Medicaid Services. Standard form: Good Faith Estimate for Health Care Items and Services under the No Surprises Act (Appendix 2). OMB 0938-1433. https://www.cms.gov/files/document/good-faith-estimate-example.pdf