An uninsured or self-pay patient books a visit and asks what it will cost. The No Surprises Act requires the practice to answer in writing, on a clock, with an itemized estimate that carries codes and dollar figures. The duty applies whether or not the patient asks, and a bill that runs $400 past the estimate opens a federal dispute the practice has to answer. Most of the exposure sits in the front desk and the fee schedule.
What this covers
- The duty attaches to uninsured patients and to insured patients who choose not to run the visit through their plan. Both count as self-pay for the estimate rule.
- Timing runs on three clocks: 1 business day when a visit is booked at least 3 business days out, 3 business days when it is booked at least 10 business days out, and 3 business days for any request.
- The estimate needs the patient’s name and date of birth, an itemized list with diagnosis and service codes, the expected charge for each item, and the practice’s NPI and TIN.
- A bill that is at least $400 over the estimate for that provider opens patient-provider dispute resolution. The patient has 120 calendar days from the initial bill to start it.
- The practice must stop collections on the disputed item while the dispute is pending, and it must answer the reviewer within 10 business days.
The estimate is a compliance document, not a courtesy. A dated, itemized copy is the practice’s first line of defense.A patient who never received one cannot be asked to accept a bill built on it.
The rule lives at 45 CFR 149.610, and it reaches any health care provider, including a solo behavioral health practice that files no claims at all. A cash-pay panel is entirely self-pay by the regulation’s definition. This article covers who is entitled to a good faith estimate, what it has to contain, the delivery clocks, how recurring care is handled, the dispute process, and the documentation to keep. The medical billing services team runs these steps inside the revenue cycle.
Who is entitled to a good faith estimate
The regulation defines an uninsured (or self-pay) individual in two parts at 45 CFR 149.610(a)(2)(xiii). The first is a person with no benefits for the item or service under a group health plan, individual or group coverage, a federal health care program, or a Federal Employees Health Benefits plan. The second has that coverage but does not seek a claim submitted for the visit. A patient with good commercial insurance who pays the posted rate sits in the second group.
| The patient | Entitled to an estimate | Why |
|---|---|---|
| No coverage at all | Yes | Uninsured under the regulation |
| Covered but paying out of pocket | Yes | Self-pay under the regulation |
| Medicare or Medicaid enrollee | No | Federal program protections apply instead |
| Emergency care | No | No opportunity to schedule in advance |
The trigger is scheduling or asking. When an individual schedules a primary item or service at least 3 business days in advance, or requests an estimate, the convening provider owes the written estimate. CMS guidance is explicit that any discussion or inquiry about the cost of an item or service counts as a request.
There is a notice duty on top of the estimate itself. Information about its availability must be written in clear language, displayed on the practice website where a public search engine can find it, and posted in the office where cost questions happen. It must also be offered in accessible formats and in the languages the practice’s patients speak. CMS publishes a model notice and form under CMS Form Number 10791, and HHS treats use of the model notice as good faith compliance.
A phone call that never becomes a booking still starts the 3-business-day clock. The front desk has to treat a price question as a request for a written estimate, not as a conversation to close.
What the estimate has to contain
The content list sits at 45 CFR 149.610(c)(1), and a single dollar figure does not satisfy it. The estimate must stand on its own as an itemized document, because the patient will compare it line by line against the bill that follows.
- Patient name and date of birth.
- A plain-language description of the primary item or service, with the scheduled date if there is one.
- An itemized list of the items and services reasonably expected for the period of care, grouped by provider or facility.
- The applicable diagnosis codes, expected service codes, and expected charge for each item.
- The name, National Provider Identifier, and Tax Identification Number of each provider or facility, plus the state and office location where care happens.
- The list of items that need separate scheduling, with its own disclaimer.
- The disclaimers: it is only an estimate, other recommended services may not appear, the patient can dispute a bill that runs $400 over, and the estimate is not a contract.
One definition matters for the numbers. Under 45 CFR 149.610(a)(2)(v), the expected charge is the cash-pay rate the practice sets for an uninsured or self-pay patient, reflecting any self-pay discount. The estimate is built from that rate, not from a billed charge the practice would send to a plan.
The estimate has to be written, on paper or electronically, based on the patient’s preference. A verbal quote is not the document the rule requires.
A first intake can be awkward, because no diagnosis has been established yet. The estimate can describe the service and the expected service code, and note that the diagnosis code will be updated once one applies.
If the estimate lists a service code and a charge for each item, the comparison against the bill is arithmetic. If it lists one lump sum, every line on the bill becomes a question. Itemize now to save the argument later.
The delivery clocks
Delivery runs on three clocks at 45 CFR 149.610(b)(1)(vi), and the shortest one is a single business day. The clock is set by how far ahead the visit is booked.
| When the service is scheduled | The estimate is due | Where it comes from |
|---|---|---|
| At least 3 business days before the visit | Within 1 business day of scheduling | 45 CFR 149.610(b)(1)(vi)(A) |
| At least 10 business days before the visit | Within 3 business days of scheduling | 45 CFR 149.610(b)(1)(vi)(B) |
| The patient asks, with nothing scheduled | Within 3 business days of the request | 45 CFR 149.610(b)(1)(vi)(C) |
| Fewer than 3 business days before the visit | No estimate is triggered by that booking | The scheduling trigger does not apply |
| The expected scope changes | A new estimate at least 1 business day before the service | 45 CFR 149.610(b)(1)(vii) |
The last row is the one practices miss. A new estimate is required when the practice anticipates or is notified of any change to the scope, including changes to expected charges, items, services, frequency, recurrences, duration, providers, or facilities. A fee increase triggers it. So does a shift from weekly to twice-weekly visits.
The convening provider also carries a coordination duty. Within 1 business day of scheduling or of the request, it must contact the co-providers expected to furnish items in support of the primary service. HHS has been exercising enforcement discretion on folding co-provider charges into the estimate itself, but the practice’s own obligation to issue its estimate on time is fully enforceable.
A visit booked three business days out leaves one business day to build and send the estimate. A front desk that collects the schedule on Friday and writes estimates on Monday has already missed it. Put the estimate inside the booking workflow instead of a weekly batch.
Recurring care: one estimate, twelve months
Behavioral health and ABA practices live on repeat visits, and the regulation accommodates that. The recurring-services provision at 45 CFR 149.610(b)(1)(x) allows a single estimate to cover recurring primary items or services if it states the expected scope: the timeframes, the frequency, and the total number of items or services. That scope cannot run past 12 months.
For an ABA practice, one document can describe a course of weekly sessions instead of a fresh estimate before every appointment. The estimate still has to be specific enough for the patient to total the expected cost.
List the primary service, for example a 97153 session, with its expected service code and the diagnosis code where one applies.
Write the expected frequency and the total number of visits the estimate covers. An estimate that says ongoing care without a count has not specified the recurring scope.
Use the practice’s actual self-pay rate, then show the total for the stated number of visits.
One recurring estimate cannot project past 12 months. Reissue at the annual mark.
A fee change, a move from weekly to twice weekly, or a new expected service needs a new estimate at least 1 business day before the next visit.
Keep the estimate and the payer authorization separate. The estimate covers expected charges to the patient. An authorization covers what a plan will pay. A change to one does not automatically update the other.
When the bill runs past the estimate
The dispute right turns on a defined number. Under 45 CFR 149.620(a)(2)(ii), substantially in excess means the total billed by that provider or facility is at least $400 more than the total expected charges on that provider’s estimate. The threshold applies to the provider’s total, not to one line item.
The patient, or an authorized representative, starts the process by filing an initiation notice within 120 calendar days of receiving the initial bill. CMS lists a $25 non-refundable administrative fee, and the process does not begin until it is paid.
| Step | Who acts | Deadline |
|---|---|---|
| File the initiation notice | Patient, through the federal portal, by mail, or electronically | Within 120 calendar days of the initial bill |
| Submit the estimate, the bill, and any supporting documentation | Provider or facility | Within 10 business days of the selection notice |
| Decide the amount the patient pays | Selected dispute resolution entity | Within 30 business days of receiving the practice’s information |
| Settle before a decision | Both parties | The practice notifies the reviewer within 3 business days of the agreement |
The reviewer weighs one question. Did the practice give credible information that the gap reflects a medically necessary item or service, based on unforeseen circumstances that could not reasonably have been anticipated when the estimate was issued. If it did, the amount is the lesser of the billed charge or a market median. If it did not, the amount is set to the estimate. A new item with no credible support is set at $0.
Collections stop while the dispute is pending. The practice must not move the disputed bill into collections, threaten to, or keep collecting if it already started, and it must suspend late fees until the process ends. It must not retaliate against the patient. A payment made before the decision does not count as agreement to settle. A settlement reduces the patient’s amount by at least half the $25 fee.
A gap the practice cannot explain as unforeseen and medically necessary is decided against it. An estimate written low to win the booking carries the difference once the reviewer looks at it.
What to document and retain
The practice’s defense is the file, not the memory. When a patient disputes a bill, the reviewer asks for the estimate that was issued and the bill that followed. A practice that cannot produce the estimate is treated as never having sent one.
- Keep a dated copy of every estimate issued, filed the way the chart is filed.
- Log the delivery: the date sent, the method, and the person who sent it.
- Record the patient’s status, uninsured or self-pay, and the question that established it.
- Keep any corrected estimate and the reason for the change.
- Compare the final bill to the estimate on file before the patient statement goes out.
- Keep the notice that the estimate is available, and note where it is posted.
- Keep dispute correspondence and any settlement notice.
The federal rule does not set a retention period for the estimate itself. The safe approach is to keep it on the same schedule as the medical record and the billing record, which state law and payer contracts already govern. Date each copy and note how it was delivered, so the practice can prove what it sent and when.
Then close the loop between the estimate and the statement. A bill that runs $400 past the estimate on file should stop before it reaches the patient. That check belongs to whoever owns patient balances, and it keeps a billing dispute out of the federal process.
The about page describes the team that runs this work, from scheduling through the final statement.
Good faith estimate questions
Any patient who is uninsured, and any patient who has coverage but chooses not to file a claim for the visit. The regulation calls the second group self-pay. Enrollees in Medicare, Medicaid, TRICARE, and other federal programs are not part of this requirement, since those programs carry their own cost protections. Emergency care is also outside it, because there is no chance to schedule in advance.
It depends on the booking. A visit scheduled at least 3 business days out needs the estimate within 1 business day of scheduling. A visit scheduled at least 10 business days out allows 3 business days. A patient who only asks for a price gets 3 business days from the request. A change in scope needs a new estimate at least 1 business day before the service.
If the total billed by that provider or facility is at least $400 more than the estimate, the patient can start patient-provider dispute resolution. The patient files within 120 calendar days of the initial bill and pays a $25 administrative fee. An independent reviewer decides what the patient pays, and the practice must send its documentation to the reviewer within 10 business days of the selection notice.
No. While the dispute is pending, the practice must not move the disputed bill into collections, threaten to do so, or keep collecting if it already started. It must also suspend late fees until the process ends, and it must not retaliate against the patient for using the process. A payment made before the decision does not count as agreement to settle.
Yes, for recurring services. The regulation allows a single estimate to cover recurring items or services if it states the expected scope, including the frequency and the total number of visits. The scope cannot run past 12 months. Past that window, or when the expected charges or the frequency change, a new estimate is required.
No. The estimate is a written projection of expected charges. The regulation states that it is not a contract and does not require the patient to obtain care from the practice. The bill is what the practice charges after care. The two documents are compared when a patient questions a charge, and that comparison is the reason the estimate carries codes and per-item charges.
The federal rule does not set a retention period for the estimate itself. The practical answer is to keep it on the same schedule as the medical record and the billing record, which state law and payer contracts already govern. File each estimate with the date and the delivery method, so the practice can prove what it sent and when.
The bottom line
The good faith estimate is a written, coded, dated document delivered on a clock, and the practice owns every part of it. Build it into scheduling, price it from the real fee schedule, and keep the copy where you can find it. A patient who received a clear estimate rarely reaches the dispute process, and a practice that can produce the file is ready when one does.
Is your estimate process ready for a cost question?
The MedFactor team builds the good faith estimate into the scheduling workflow, ties it to the fee schedule, and keeps the file that answers a dispute. We will review how your practice handles uninsured and self-pay patients and show you where the clocks and the content fall short. You can schedule an appointment for that review.
Request a free estimate compliance auditThis article is general information about the No Surprises Act good faith estimate requirements, not legal advice, and the current regulation at 45 CFR 149.610 and 149.620 controls.
