Under the No Surprises Act, a health care provider must give a good faith estimate (GFE) of expected charges to any uninsured or self-pay individual — either when that person schedules an item or service, or when they simply ask what it will cost. The rule lives at 45 CFR 149.610, and it is more operational than most practices realize: it puts a clock on you (as little as one business day), it requires you to ask every patient about their coverage, and it treats any discussion about the potential cost of care as a request for an estimate. This is a front-office process, not a billing-department process. If your schedulers do not know the rule, you are not complying with it.
Who gets one, and when
An uninsured (or self-pay) individual, as the rule defines it, is either (a) someone with no benefits for the item or service under a group health plan, individual or group coverage, a federal health care program, or a FEHB plan, or (b) someone who has such benefits but does not seek to have a claim submitted for the item or service. That second category is the one practices miss. A fully insured patient who says "just bill me directly, I do not want this going through my insurance" is a self-pay individual for that service, and the GFE obligation attaches.
The rule places three affirmative duties on the convening provider before a GFE is ever drafted:
- Ask. Inquire whether the individual is enrolled in a plan, coverage, or a federal health care program.
- Ask again. If they are enrolled, inquire whether they are seeking to have a claim submitted for the primary item or service.
- Tell. Inform all uninsured or self-pay individuals that a good faith estimate is available, both upon scheduling and upon request.
And that notice of availability is not a line in a binder. The rule requires it to be written in clear and understandable language, prominently displayed and easily searchable from a public search engine on your website, posted in the office and on-site wherever scheduling or cost questions happen, provided orally when scheduling or when cost questions come up, and made available in accessible formats and in the languages spoken by the individuals you serve.
The clocks you are actually running
The timing is defined by when the service is scheduled relative to the appointment — not by when you get around to it.
| Trigger | Deadline to deliver the GFE |
|---|---|
| Primary item or service scheduled at least 3 business days before it is furnished | Not later than 1 business day after scheduling |
| Primary item or service scheduled at least 10 business days before it is furnished | Not later than 3 business days after scheduling |
| GFE requested by an uninsured or self-pay individual (no scheduling yet) | Not later than 3 business days after the request |
| Anticipated change in scope after scheduling (charges, items, services, frequency, duration, providers) | A new GFE, no later than 1 business day before the service is furnished |
There is a second, quieter clock. Within one business day of scheduling or of the request, the convening provider must contact every co-provider and co-facility reasonably expected to furnish items or services in conjunction with the primary service, and request their GFE information — including the date by which you need it back. Co-providers then have one business day from receiving your request to send it.
What must be on the estimate
45 CFR 149.610(c)(1) is a content checklist. A compliant GFE includes:
- Patient name and date of birth.
- A description of the primary item or service in clear, understandable language — and, if scheduled, the date.
- An itemized list of items and services reasonably expected to be furnished for that period of care, grouped by each provider or facility, including those expected from co-providers and co-facilities.
- Applicable diagnosis codes, expected service codes, and expected charges for each listed item or service.
- The name, NPI, and TIN of every provider or facility represented in the estimate, plus the state and office or facility location where the items or services are expected to be furnished.
- A list of items or services that will require separate scheduling and are expected to occur before or after this period of care, with a disclaimer directly above the list explaining that separate GFEs will be issued for them and how to obtain them.
- A disclaimer that there may be additional recommended items or services that must be scheduled separately and are not reflected in the estimate.
- A disclaimer that this is an estimate, and that actual items, services, or charges may differ.
- A disclaimer explaining the patient's right to initiate the patient-provider dispute resolution process if billed charges are substantially in excess of the estimate, where to find instructions, and a statement that using the process will not adversely affect the quality of care they receive.
- A disclaimer that the GFE is not a contract and does not require the individual to obtain the items or services from any provider listed.
Delivery must be in writing — on paper or electronically, per the patient's requested method — in a form they can save and print, in clear language calculated to be understood by the average patient. You may read the estimate to a patient who asks for it by phone, but you must still issue the written version.
Two provisions everybody forgets
- The GFE is part of the medical record. Per 149.610(f)(1), it is considered part of the patient's medical record and must be maintained the same way — and you must provide a copy of any GFE issued within the last six years on request.
- Recurring services get one GFE, capped at 12 months. A single estimate may cover recurring primary items or services if it clearly states the expected scope (timeframes, frequency, total number), and the scope may not exceed 12 months.
The conversation that triggers it
The most consequential sentence in the rule is short: convening providers shall consider any discussion or inquiry regarding the potential costs of items or services under consideration as a request for a good faith estimate.
Read that again from the front desk's perspective. "About how much is that going to run me?" is a request. It starts a three-business-day clock. It does not matter that the patient did not use the words "good faith estimate," and it does not matter that they never scheduled.
So the script matters. Train the desk to recognize the trigger, log it, and respond — something like: "I can get you a written good faith estimate of what this is expected to cost. Are you planning to have this billed to insurance, or handling it yourself? Would you like the estimate by email or on paper?" That single exchange captures the coverage question, the self-pay determination, and the delivery preference, and it timestamps the request.
Convening providers vs. co-providers
| Role | Who it is | What they owe |
|---|---|---|
| Convening provider | The one who receives the initial request or is responsible for scheduling the primary item or service | Determine self-pay status; notify of GFE availability; contact co-providers within 1 business day; assemble and deliver the full GFE on the clock |
| Co-provider | Anyone else furnishing items or services customarily provided in conjunction with the primary service (anesthesia, pathology, imaging, labs) | Return GFE information to the convening provider within 1 business day of the request; notify of any anticipated scope change |
One nuance worth knowing: if a self-pay patient separately schedules or separately requests an estimate from a provider who would otherwise be a co-provider, that provider becomes a convening provider for that service and owes the full set of obligations themselves.
And a trap: if a provider or facility in the GFE is swapped out less than one business day before the service, the replacement must accept the replaced provider's estimated charges as its own good faith estimate.
The $400 rule and the dispute process
The number that gives the GFE its teeth is in 45 CFR 149.620. Substantially in excess means billed charges that are at least $400 more than the total expected charges listed on the good faith estimate for that provider or facility. When that happens, the patient may initiate the patient-provider dispute resolution process by submitting an initiation notice, postmarked within 120 calendar days of receiving the initial bill.
What that means operationally, once a dispute is pending:
- You must not move the disputed bill into collections or threaten to, and if it is already in collections, you should cease collection efforts.
- You must suspend the accrual of late fees on the unpaid amount until the process concludes.
- You must not take or threaten any retributive action against the patient for using the process.
- You have 10 business days from the selection notice to submit your GFE, your billed charges, and any documentation showing the difference reflects a medically necessary item or service based on unforeseen circumstances that could not reasonably have been anticipated.
- If you cannot show that with credible information, the resolution entity sets the amount payable at the estimated charge — and for a new item or service not on the GFE at all, potentially at $0.
That is the real financial incentive to build the estimate properly. A thin, optimistic GFE is not a courtesy to the patient — it is a cap on what you can collect.
Building the workflow
- Post the notice. Website (prominently displayed, searchable), waiting room, scheduling desk, and anywhere cost comes up. Accessible formats and the languages your patients speak.
- Script the two questions into the scheduling flow, and make the answers a required field.
- Add a trigger. Any cost inquiry gets logged with a timestamp and generates a task — because it started a clock.
- Maintain a co-provider map by service line, so "who else touches this case" is a lookup, not an investigation.
- Template the GFE with every required content element, including all five disclaimers, so nothing is rebuilt by hand.
- Build the change trigger. Any anticipated scope change generates a new GFE no later than one business day before the service.
- Store it in the chart — it is part of the medical record — and retain it for six years.
- Flag the variance. Before a self-pay bill goes out, compare billed charges to the GFE. If the gap is approaching $400, that is the moment for a phone call, not a statement.
Practices that treat the GFE as a billing formality end up defending estimates they never really built. Practices that treat it as a front-desk conversation — asked, answered, logged, delivered — find it costs about ninety seconds per patient and prevents nearly every downstream dispute.
Common questions
Do we owe a good faith estimate to an insured patient?
Yes, if they are choosing not to have a claim submitted for that item or service. The rule defines an uninsured or self-pay individual to include someone who has coverage but does not seek to have a claim submitted. That is why you must ask both questions, not just whether they have insurance.
Does a patient asking "what will this cost?" count as a request?
Yes. The rule directs convening providers to consider any discussion or inquiry regarding the potential costs of items or services under consideration as a request for a good faith estimate — which starts a three-business-day clock.
What is the $400 threshold?
45 CFR 149.620 defines "substantially in excess" as billed charges at least $400 more than the total expected charges on the good faith estimate for that provider or facility. Above that, the patient may initiate patient-provider dispute resolution within 120 calendar days of the initial bill.
How long do we have to keep a good faith estimate?
It is considered part of the patient's medical record and must be maintained accordingly. You must be able to provide a copy of any GFE issued within the last six years upon the patient's request.
Common questions
Do we owe a good faith estimate to an insured patient?
Yes, if they are choosing not to have a claim submitted for that item or service. 45 CFR 149.610 defines an uninsured or self-pay individual to include someone who has coverage but does not seek to have a claim submitted. That is why you must ask both questions, not just whether they have insurance.
Does a patient simply asking what something will cost count as a request?
Yes. The rule directs convening providers to consider any discussion or inquiry regarding the potential costs of items or services under consideration as a request for a good faith estimate, which starts a three-business-day clock.
What is the $400 threshold in the No Surprises Act?
45 CFR 149.620 defines 'substantially in excess' as total billed charges at least $400 more than the total expected charges listed on the good faith estimate for that provider or facility. Above that, the patient may initiate the patient-provider dispute resolution process within 120 calendar days of receiving the initial bill.
How long must we keep a good faith estimate?
The GFE is considered part of the patient's medical record and must be maintained in the same manner. You must provide a copy of any GFE issued within the last six years upon the individual's request.