Good Faith Estimate Requirements Under the No Surprises Act

The requirement sits at 45 CFR 149.610, issued under the No Surprises Act. Per 149.610(g)(1), it is applicable to estimates requested on or after 1 January 2022, or required in connection with items or services scheduled on or after that date.

Who must give one. Any health care provider or facility that schedules an item or service for, or receives a GFE request from, an uninsured or self-pay individual. The regulation defines provider as a physician or other health care provider acting within the scope of their license or certification under State law, including air ambulance providers, and facility as an institution licensed as such under State or local law — the definition names hospitals and hospital outpatient departments, critical access hospitals, ambulatory surgical centers, rural health centers, federally qualified health centers, laboratories and imaging centers as examples.

Who is entitled to receive one. 149.610(a)(2)(xiii) defines an uninsured (or self-pay) individual as either:

• (A) an individual with no benefits for the item or service under a group health plan, group or individual coverage from a health insurance issuer, a Federal health care program, or a FEHB health benefits plan; or
• (B) an individual who has benefits under a group health plan, group or individual coverage from a health insurance issuer, or a FEHB plan, but does not seek to have a claim submitted to that plan or coverage.

Read (B) closely. It lists commercial and FEHB coverage; it does not list Federal health care programs. CMS's own provider guidance states the point directly: enrollees in Federal health care programs are not eligible to receive a good faith estimate, because other surprise billing protections apply under those programs. So a commercially insured patient who says "don't bill my insurance" is a self-pay individual and is owed an estimate; a Medicare, Medicaid or TRICARE beneficiary making the same statement is a different question and should not be routed through this workflow by reflex.

The determination is a required step, not an inference. 149.610(b)(1)(i)-(ii) requires the convening provider to ask whether the individual is enrolled in any of those coverages, and, if they are enrolled in commercial or FEHB coverage, to ask whether they are seeking to have a claim submitted. Registration scripts have to carry both questions.

The notice requirement almost nobody implements. 149.610(b)(1)(iii) requires that information about the availability of a GFE be written in clear and understandable language and prominently displayed — and easily searchable from a public search engine — on your website, in the office, and on-site wherever scheduling or cost questions occur; provided orally when scheduling or when cost questions arise; and made available in accessible formats and in the languages spoken by the individuals scheduling with you. A practice that generates perfect estimates but has nothing on its website is non-compliant on a provision that takes an afternoon to fix. CMS publishes a model notice for exactly this.

And the trigger is broader than the word "request" suggests. 149.610(b)(1)(iv) requires convening providers to treat any discussion or inquiry regarding the potential costs of items or services under consideration as a request for a Good Faith Estimate. "How much would this cost if I paid cash?" starts a 3-business-day clock, whether or not anything was scheduled.

The most common workflow gap is narrower than any of this: a scheduling trigger built for patients with no insurance at all, which never fires for the insured patient electing to pay cash. Both populations are in scope. For the broader patient-financial workflow this sits inside, see our patient billing and collections services.

Timing is the most-failed part of the rule, and the regulation actually sets five separate clocks, not one. All are measured in business days, and all are in 45 CFR 149.610(b).

Reading the clock correctly. Each scheduling row pairs a minimum lead time with a response deadline. A patient who books 4 business days ahead meets the "at least 3 business days" condition, so the estimate is due within 1 business day of the booking. A booking fewer than 3 business days out does not trigger a scheduling deadline — but a request still triggers the 3-business-day clock independently.

Changes in scope. Under 149.610(b)(1)(vii), if the convening provider, convening facility, co-provider or co-facility anticipates or is notified of any change to the scope of the estimate — expected charges, items, services, frequency, recurrences, duration, providers or facilities — a new GFE is due no later than 1 business day before the items or services are scheduled to be furnished.

Late substitutions. Under 149.610(b)(1)(viii) and (b)(2)(iii), if a provider or facility named in the estimate is replaced less than 1 business day before service, the replacement must accept the replaced party's estimate as its own for the relevant items or services. Your contracting and scheduling teams should know this: a last-minute locum or covering group inherits somebody else's number.

Recurring services. 149.610(b)(1)(x) permits a single GFE for recurring primary items or services, provided it states the expected scope — timeframes, frequency and total number — clearly, and provided the scope does not exceed 12 months. Beyond 12 months, a new estimate is required, with the changes communicated on delivery. For therapy, behavioral health and other recurring-visit practices this is the provision that makes the rule workable at all.

When a co-provider is asked directly. Under 149.610(b)(2)(iv), if the individual separately schedules with, or requests an estimate from, a party that would otherwise be a co-provider, that party becomes a convening provider for those items and takes on the full set of convening obligations.

Because every window is short, the durable fix is to generate the estimate as a byproduct of scheduling itself, at the moment a self-pay or uninsured appointment is booked, rather than as a separate task someone has to remember.

A compliant GFE is not a price quote. 45 CFR 149.610(c)(1) lists the elements, and an estimate missing any of them is non-compliant even if the dollar figure is right.

Two of those are routinely dropped. Element 7 — the recommended-but-separately-scheduled disclaimer — and the non-retaliation sentence inside element 9 are both easy to omit when a template is written from a summary rather than from the regulation.

How it must be delivered. Per 149.610(e), in writing, on paper or electronically according to the individual's requested method; electronic estimates must be deliverable in a form the individual can both save and print; and the estimate must be written in clear and understandable language calculated to be understood by the average uninsured or self-pay individual. An oral answer is permitted in addition, on request — but the written estimate still has to be issued.

Retention, stated precisely. 149.610(f)(1) makes the GFE part of the patient's medical record, maintained in the same manner as the medical record, and requires the convening party to provide a copy of any previously issued estimate furnished within the last 6 years on the individual's request. The six years is the look-back for producing a copy on request; the retention standard itself is whatever governs your medical records.

The good-faith error provision. Under 149.610(f)(3), a provider does not fail to comply solely because, despite acting in good faith and with reasonable due diligence, it makes an error or omission — provided it corrects the information as soon as practicable. Under (f)(4), a provider that relied in good faith on information from another entity does not fail to comply unless it knew or reasonably should have known the information was incomplete or inaccurate. Neither provision helps once the service has been furnished: the regulation says the provider may still be subject to dispute resolution if the billed charges end up substantially in excess of the estimate.

When an episode involves more than one party, the rule assigns roles so the individual receives one coordinated estimate.

Convening provider or convening facility — per 149.610(a)(2)(ii), the party that receives the initial request for an estimate and is, or in the case of a request would be, responsible for scheduling the primary item or service. It owns the estimate and delivers it.

Co-provider or co-facility — per 149.610(a)(2)(iii), a party other than the convening one that furnishes items or services customarily provided in conjunction with the primary item or service. Anesthesia, pathology and the facility associated with a scheduled procedure are the usual examples.

The assembly sequence, with its clocks:

1. On scheduling or on a request, the convening provider identifies the co-providers reasonably expected to be involved.
2. Within 1 business day, it contacts them and requests their estimate information, stating the date it is due back.
3. Each co-provider returns its information within 1 business day of the request — patient name and date of birth, its itemised items and services, diagnosis and service codes and expected charges, its name, NPI and TIN and locations, and the not-a-contract disclaimer (149.610(d)(1)).
4. The convening provider assembles and delivers one estimate inside the applicable timing window.

The enforcement discretion, stated accurately. The regulation requires co-provider charges to be included. HHS has never enforced that part. The original interim final rule exercised enforcement discretion for estimates furnished from 1 January 2022 through 31 December 2022, and CMS then extended it: in its FAQ guidance on good faith estimates for uninsured (or self-pay) individuals, asked whether estimates must include cost estimates from co-providers and co-facilities beginning on 1 January 2023, CMS answered "No. HHS is extending enforcement discretion, pending future rulemaking, for situations where GFEs for uninsured (or self-pay) individuals do not include expected charges from co-providers or co-facilities." CMS added that any rulemaking fully implementing the requirement will carry a prospective applicability date giving providers reasonable time to comply, and that it encourages States that are primary enforcers to take the same approach while the discretion is in effect. Read 17 September 2026; the guidance is published at cms.gov.

What that means operationally. The discretion is open-ended and ends with a rule, not a date — so it is not something to build a permanent process around, but it is also not something to panic about. Three consequences worth planning for:

• Your own expected charges are the non-negotiable baseline. The discretion covers other parties' charges, not yours.
• A co-provider's items that appear without an expected charge, or as a range, are correspondingly outside dispute resolution for that co-provider's items — which cuts both ways, and means an individual seeking certainty on an anesthesia or pathology charge is better served by requesting an estimate from that party directly.
• An individual can always ask a co-provider directly, and when they do, that party becomes a convening provider with the full set of obligations.

The durable position is to estimate your own charges completely and accurately every time, coordinate co-provider amounts where you reasonably can, and keep the assembly workflow warm — because the rulemaking that closes this will arrive with a compliance date attached.

The estimate has teeth because of the Patient-Provider Dispute Resolution (PPDR) process at 45 CFR 149.620.

"Substantially in excess" is defined, not judged. The regulation states: "Substantially in excess means, with respect to the total billed charges by a provider or facility, an amount that is at least $400 more than the total amount of expected charges listed on the good faith estimate for the provider or facility." The comparison is per party — each provider's or facility's billed total against the expected charges attributed to that same party, not against the estimate as a whole.

The filing window. The individual (or an authorised representative, excluding parties connected to the providers on the estimate) initiates by submitting an initiation notice to HHS postmarked within 120 calendar days of receiving the initial bill containing the charges that are substantially in excess.

A selected dispute resolution (SDR) entity decides. The determination rules, as the regulation states them:

Fees. The regulation provides for an administrative fee to participate, with the amount specified by the Secretary through guidance rather than fixed in the rule, so check the current figure rather than quoting an old one.

Why this matters operationally. An under-scoped estimate is not a way to look cheaper — it is a way to lose the difference. The bottom row is the sharp one: an item you never listed, and cannot justify as unforeseen and medically necessary, is determined at zero. The compliant move and the financially sound move are the same move: estimate the full expected scope, document anything unforeseen that drove a higher bill, and reissue the estimate when scope changes materially before the date of service.

Below is a worked example showing the required elements assembled into one document. This is an on-page illustration, not a downloadable form — and you do not need ours, because CMS publishes its own. HHS has developed a model template and notice, published as CMS Form Number 10791, which providers may use to prepare estimates and to notify individuals of their availability; CMS states that use of the model is not required and is provided as a means of facilitating compliance. The standard form is at cms.gov and the availability notice at cms.gov. Adopting the model is the fastest way to satisfy the format and disclaimer requirements, and it is what we would put in front of a practice building this from scratch.

The example below is built around a synthetic self-pay diagnostic upper endoscopy in an outpatient endoscopy centre setting, because that episode pulls in a facility fee, a physician fee, anesthesia and pathology and therefore exercises the convening-provider and co-provider elements together. The patient, providers, codes and dollar figures are invented for illustration. A different setting — an office-based procedure, a behavioural health course of care, a therapy series under the 12-month recurring-services provision — produces a materially different estimate.

GOOD FAITH ESTIMATE OF EXPECTED CHARGES

Patient: Jane Q. Sample | DOB: 04/12/1986 | Date of Estimate: 17 September 2026

Primary service: Diagnostic upper endoscopy, outpatient endoscopy centre, scheduled 7 October 2026

Convening facility: Example GI Center | NPI: 1234567890 | TIN: 12-3456789 | 100 Main St, Anytown, ST

Items the convening facility anticipates will require separate scheduling (disclaimer sits directly above this list): separate Good Faith Estimates will be issued on scheduling or on request for the pre-procedure consultation and any follow-up visit; codes, charges and provider identifiers are not shown here because they will appear in those separate estimates; to obtain them, call the number on this estimate or ask at scheduling.

Required disclaimers:

• There may be additional items or services we recommend as part of your course of care that must be scheduled or requested separately and are not reflected in this estimate.
• This Good Faith Estimate is only an estimate of items and services reasonably expected at the time it was issued; actual items, services or charges may differ.
• You have the right to initiate the Patient-Provider Dispute Resolution process if your billed charges are substantially in excess of the expected charges in this estimate. Instructions for how to initiate it are [here — insert the link or phone number you publish]. Initiating a dispute will not adversely affect the quality of health care services furnished to you.
• This Good Faith Estimate is not a contract and does not require you to obtain the listed items or services from any of the providers or facilities identified in it.

Keep a copy of this Good Faith Estimate. You may need it if you are billed more than the estimate.

Because the windows are measured in business days and the dispute exposure is real money, the estimate has to be an operational reflex rather than a memory test.

1. Publish the notice first. Before any of the workflow below, satisfy 149.610(b)(1)(iii): put the availability notice on your website where a public search engine can find it, in the office, and on-site wherever scheduling or cost questions happen; in accessible formats and in the languages your patients speak. Use CMS's model notice. This is the cheapest compliance item in the rule and the one most often missing.

2. Ask both coverage questions at scheduling and registration. Is the individual enrolled in a group health plan, individual or group coverage, a Federal health care program, or a FEHB plan? And if they are enrolled in commercial or FEHB coverage, are they seeking to have a claim submitted for this item or service? Those two questions are what 149.610(b)(1)(i)-(ii) requires, and the second is the one that catches the insured patient electing to pay cash.

3. Treat cost inquiries as requests. Train the front desk and phone staff that any discussion of what something might cost is a request under 149.610(b)(1)(iv), starting a 3-business-day clock. Log it the moment it happens; you cannot meet a deadline you did not know had started.

4. Auto-generate the estimate from the encounter's expected codes. Map the scheduled service to its expected service codes, diagnosis codes and charge-master amounts so the estimate populates rather than being keyed by hand. This is the same data discipline that drives accurate charge entry downstream.

5. Calendar all the clocks, not just the patient-facing one. The scheduling system should calculate the GFE deadline (1 or 3 business days), the co-provider outreach deadline (1 business day), and the co-provider response date, and track all three. Note which of those the current enforcement discretion softens and which it does not.

6. Deliver in writing, in the requested format, and log delivery. Paper or electronic per the individual's request, savable and printable if electronic, in plain language, with proof of delivery recorded.

7. Retain it as part of the medical record, and make sure you can produce a copy of anything furnished in the last 6 years on request.

8. Reissue on material change. Any change to expected charges, items, services, frequency, recurrences, duration, providers or facilities means a new estimate no later than 1 business day before service — and it is your strongest position if the bill is later disputed.

9. Use the recurring-services provision where it fits. For a course of care, one estimate covering up to 12 months with the scope stated is both compliant and far less work than one per visit.

The rule is procedurally simple and operationally easy to botch. The failure patterns below map to specific provisions, so each has a control you can implement rather than a habit you have to remember.

1. Scoping only to the uninsured. A trigger built for patients with no coverage never fires for the commercially insured patient electing to pay cash, who is squarely inside 149.610(a)(2)(xiii)(B). Control: the second coverage question is mandatory at registration.

2. Never publishing the availability notice. 149.610(b)(1)(iii) requires it on the website, in the office, on-site, orally, in accessible formats and in the relevant languages. Control: treat it as a launch item, not an ongoing task.

3. Not recognising a cost inquiry as a request. Under 149.610(b)(1)(iv) it is one. Control: a logged "cost inquiry" disposition in the phone and front-desk workflow.

4. Counting calendar days, or starting the clock at the date of service. The windows are business days and they run from the date of scheduling or the date of the request. Control: the scheduling system calculates the date; nobody counts by hand.

5. Forgetting the co-provider clocks. The 1-business-day outreach and 1-business-day response obligations exist in the regulation whatever the enforcement posture on including the charges. Control: calendar them alongside the patient-facing deadline.

6. Under-scoping to look affordable. Omitting expected anesthesia, pathology or facility fees makes the number smaller and the dispute exposure larger, and an item never listed at all can be determined at $0 in dispute resolution if it cannot be justified as unforeseen and medically necessary.

7. Missing codes or disclaimers. A price quote without service codes, diagnosis codes, NPI and TIN, or the full set of disclaimers — including the non-retaliation sentence and the recommended-but-separately-scheduled disclaimer — is not a compliant estimate even if the total is right. Control: build from CMS's model form rather than from a summary.

8. No reissue after a scope change. 149.610(b)(1)(vii) requires a new estimate no later than 1 business day before service. Control: tie reissue to the same event that changes the appointment.

9. Not retaining it. The estimate is part of the medical record and must be producible for six years on request. A practice that cannot produce the estimate it issued has no position in a dispute.

The downstream connection. A self-pay encounter mishandled at the estimate stage resurfaces later as a patient-balance dispute or a write-off — the patient-financial analogue of a clean-claim failure. Where insurance turns out to be involved after all, the cost-sharing shows up as PR-1, PR-2 and PR-3 patient-responsibility adjustments, with their own rules about what you may actually bill. Getting the data and the disclosure right before the service is the same prevention philosophy that keeps the back end clean.