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No Surprises Act

Good Faith Estimate

As of January 1, 2022, state-licensed or certified health care providers need to give a Good Faith Estimate of healthcare charges to every new and continuing client who is either uninsured or is not planning to submit a claim to their insurance for the healthcare services they seek.

 

Which clients need to be given a Good Faith Estimate?

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Any client who is uninsured—or who is insured but does not plan to use their insurance benefits to pay for the health care services you provide—should be provided a Good Faith Estimate. A Good Faith Estimate is not necessary at this time for a client or patient who is planning to use their insurance benefits to cover your services. (“At this time” is a key phrase there, as HHS has said that future rulemaking will address Good Faith Estimate obligations to this group.)

The Good Faith Estimate provisions do not apply if the client is a participant in Medicare, Medicaid, or other federal healthcare programs. Good Faith Estimates are also not generally required for emergency services, which by their nature cannot be scheduled in advance. 

What information needs to be included in a Good Faith Estimate?

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The Good Faith Estimate must include all of the following:

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• Client name 

• Client date of birth

• Description of the services that will be provided, in understandable language

• Itemized list of goods or services reasonably expected to be provided in connection with the scheduled services

• Diagnostic codes, service codes, and expected charges associated with each of those goods or services

• Provider name, NPI, and tax ID number

• Office location where services will be provided

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Some disclaimers to note: 

• The provider may recommend additional items or services as part of the treatment that are not reflected in the estimate. These would need to be scheduled separately. 

• The information provided in the Good Faith Estimate is only an estimate, as actual items, services, or charges may differ. 

• The client has the right to engage in a dispute resolution process if the actual costs of services significantly ( more than $400.00) exceed those listed in the Good Faith Estimate. 

• The Good Faith Estimate does not obligate or require the client to obtain any of the listed services from the provider.

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The list of services to be provided should differentiate between those services that the provider will be offering, and those offered through what the law defines as co-providers and co-facilities:

 

Others who will be providing services related to the treatment being sought. 

In addition to the estimate itself, clients who are not using their insurance benefits to pay for services must also be given notice of their right to receive a Good Faith Estimate upon request. 

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When do clients need to be given the Good Faith Estimate?

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The law puts forth specific guidelines for when a client must be given a Good Faith Estimate.

 

• If a service is scheduled at least 10 business days in advance, the Good Faith Estimate must be provided within 3 business days. (This is within 3 business days of the scheduling, not of the appointment itself.)

• If a service is scheduled at least 3 business days in advance, the Good Faith Estimate must be provided within 1 business day of scheduling.

• If a service is scheduled less than 3 business days in advance, a Good Faith Estimate is not required.

• If an individual requests a Good Faith Estimate, it must be provided within 3 business days.

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The Good Faith Estimate rules “do not require the good faith estimate to include charges for unanticipated items or services that are not reasonably expected and that could occur due to unforeseen events.” If a clients’ needs are ultimately different from what was expected, a provider can update the Good Faith Estimate to address the new information or events.

 

For more info on the "No Surprises Act" click this link: https://www.cms.gov/nosurprises

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