Good Faith Estimate Requirements: The No Surprises Act Rule in Plain Language
If a patient is uninsured or chooses not to use insurance, you must hand them a written estimate of what you expect to charge, on a federal deadline, with specific contents. This guide walks through 45 CFR § 149.610 section by section: who it covers, when the estimate is due, what goes in it, and what happens when the final bill runs $400 over.
FIG · 0145 CFR § 149.610 AT A GLANCE
In force since Jan 1, 20221 or 3
business days
to deliver after scheduling
$400
over estimate
opens patient dispute
12
months max
per recurring-care GFE
6
years
copies must stay retrievable
Applies to every licensed provider and facility, not just hospitals. Solo therapists included.
Open the GFE generator
FIG · 02Who Must Issue a Good Faith Estimate
The rule applies to any health care provider or facility licensed, certified, or approved by a state. Physicians, dentists, therapists, physical therapists, chiropractors, labs, imaging centers, ambulatory surgery centers. If you can bill for care, you can be a convening provider: the one who receives the request or schedules the primary service and is responsible for the estimate.
The patient side is what trips practices up. The regulation defines an uninsured (or self-pay) individual as someone who either has no benefits for the item or service, or who has coverage but does not intend to have a claim submitted. Insured patients who go out of pocket are self-pay for GFE purposes. Their insurance card does not exempt you.
GFE required
- Patient has no health coverage at all (no plan, no Medicare, no Medicaid)
- Patient has coverage but tells you not to bill it for this service
- Patient asks for an estimate before deciding whether to book
- Cash-pay practices that never bill insurance (every patient qualifies)
Not required today
- Insured patient whose claim you will submit (the plan-facing GFE and AEOB are not yet enforced)
- Emergency services, which are covered by separate balance-billing rules
- Medicare or Medicaid beneficiaries when you bill the program
Two more duties come with the territory. When a patient schedules or asks about costs, you must ask whether they are enrolled in a plan and whether they want a claim submitted, then tell them a GFE is available. And you must post a plain-language notice about the GFE right on your website, in the office, and on-site where scheduling happens. Most practices fold the question into the intake form next to the Notice of Privacy Practices acknowledgment.
Timing: The 1-Day and 3-Day Rules
The clock starts at scheduling (or at the request), not at the appointment. Counterintuitively, a soon appointment gets the shorter deadline: book someone for next week and the estimate is due tomorrow.
| Trigger | GFE due | § 149.610 |
|---|---|---|
| Scheduled at least 10 business days before the service | 3 business days after scheduling | (b)(1)(ii)(B) |
| Scheduled at least 3 business days before the service | 1 business day after scheduling | (b)(1)(ii)(A) |
| Patient requests an estimate (nothing scheduled) | 3 business days after the request | (b)(1)(ii)(C) |
| Anything about the expected charges changes | New GFE no later than 1 business day before the service | (b)(1)(vi) |
EXAMPLE: PATIENT BOOKS ON MONDAY FOR NEXT THURSDAY (8 BUSINESS DAYS OUT)
- MONScheduled
- TUEGFE due (1-day rule)
- WEDLast day for a revised GFE
- THUService
Eight business days is under the 10-day threshold, so the 1-business-day deadline applies, not the 3-day one.
Same-week bookings: if the service is fewer than 3 business days out, no deadline in the regulation fires, but the obligation to provide a GFE on request still does. The safe workflow is one GFE at the moment of scheduling, every time, regardless of lead time. The regulation requires it in writing (paper or electronic, in the patient's chosen format) even when you also explain it verbally.
What the Estimate Must Contain
Section 149.610(c)(1) lists the required content. Miss an element and the GFE is deficient even if the math is right. Nine things, every time:
Patient name and date of birth
Exactly as they appear in your records
Description of the primary service in clear language
Plus the scheduled date, if one exists
Itemized list of every expected item or service
Grouped by provider or facility, including expected ancillary items
Diagnosis codes and service codes
ICD-10 where applicable; CPT, HCPCS, DRG, or NDC for services
Expected charge for each item
The cash price you actually expect to charge, with any self-pay discount applied
Provider name, NPI, and TIN
For each provider or facility on the estimate
Office or facility location
Where each service will be furnished
Items that require separate scheduling
Flagged as expected to be scheduled separately
Required disclaimers
See the list below — all four, verbatim in substance
The four disclaimers
The regulation spells out four notices the document itself must carry:
- There may be additional items or services the convening provider recommends that are not reflected in this estimate
- This estimate is only an estimate — actual charges may differ
- The patient has the right to initiate patient-provider dispute resolution if billed substantially in excess (the $400 rule), and doing so will not affect the quality of their care
- This good faith estimate is not a contract and does not obligate the patient to obtain the services
Skip the formatting work. Our free Good Faith Estimate generator produces all nine elements and the disclaimer block automatically — enter your services and charges, then print or save.
Retention: the GFE is part of the patient's record, and you must be able to provide a copy of any estimate issued in the past 6 years on request. Track it the way you track training documentation — dated, filed, retrievable. Clean documentation habits make the 6-year rule painless.
The Co-Provider Rule: Written but Not Enforced
As written, § 149.610(b)(2) makes the convening provider assemble one comprehensive estimate: request expected charges from every co-provider and co-facility (the anesthesiologist, the lab, the surgery center) within 1 business day of scheduling, get their numbers back within 1 business day, and fold everything into a single document.
Status as of August 2026: enforcement discretion, still in effect
CMS announced in December 2022 (FAQ guidance) that it would not enforce the co-provider/co-facility bundling requirement, “pending further rulemaking,” because the data exchange infrastructure between separate practices does not exist. That discretion has never been lifted. No final rule has set a new compliance date as of August 2026.
Practical effect: your GFE only needs to cover items YOUR practice will bill. Co-providers issue their own GFEs on request.
Related and also on hold: the statute's GFE for insured patients, which would flow to the health plan to power an Advanced Explanation of Benefits (AEOB). Those provisions remain unenforced pending rulemaking too — the federal regulatory agenda points at a proposed AEOB rule in late 2026, but nothing binds providers yet. Watch this one: when it lands, GFE volume jumps from your self-pay patients to nearly everyone you schedule.
The $400 Patient-Provider Dispute Process
The GFE has teeth because of 45 CFR § 149.620. Bill an uninsured or self-pay patient at least $400 more than the estimate and they can take the bill to federal patient-provider dispute resolution (PPDR). It is one of the core patient rights created by the No Surprises Act.
Bill lands $400+ over the GFE total
The threshold applies to the total billed by that provider vs. the GFE total — several small overages that add up to $400 count.
Patient files within 120 calendar days
Through the federal PPDR portal at cms.gov, with a $25 administrative fee (waivable for hardship).
Collections freeze
Once notified, you must not send the disputed bill to collections, must pause existing collection activity, and must suspend late fees while the dispute is open.
An SDR entity reviews the paper trail
A federally contracted Selected Dispute Resolution entity compares the bill against the GFE.
Binding determination
For items on the GFE, you get the GFE amount unless you show credible evidence the extra charge was unforeseen and medically necessary. Items missing from the GFE default to $0 absent that evidence, or at best the lesser of the billed charge and a median market rate.
The determination binds you, not the patient. If the SDR entity rules for the patient, the $25 fee is credited against what they owe you. A charge you forgot to list is the worst position: the default outcome is that you collect nothing for it. Estimating slightly high and itemizing everything beats estimating optimistically.
Penalties and Enforcement
GFE enforcement looks different from HIPAA enforcement. There is no OCR-style audit machine yet; the pressure comes from three directions:
Civil monetary penalties
The No Surprises Act (PHSA § 2799B-4) authorizes penalties of up to $10,000 per violation for providers. States enforce first; HHS steps in where a state does not.
PPDR losses
Every disputed bill you lose is written down to the GFE amount — or to $0 for unlisted items. This is the enforcement mechanism practices actually feel.
State-law exposure
Many states layer their own surprise-billing and estimate statutes on top of the federal floor, with separate penalty schedules and complaint processes.
There is a safety valve: the statute directs HHS to waive the penalty where the provider did not knowingly violate the rule, withdraws the bill, and refunds any excess with interest. Good-faith mistakes that get corrected are survivable. A pattern of never issuing estimates is not — and unlike a HIPAA violation, the evidence is a document you either have on file or don't. Fold GFE issuance into your compliance work plan and spot-check it during internal audits.
Worked Example: A Therapy GFE for Six Months of Care
A self-pay client books a Tuesday intake on the preceding Wednesday — four business days out, so the GFE is due Thursday (the 1-business-day rule). The therapist expects weekly sessions for six months. Because therapy is recurring care, one GFE can cover the whole expected course — up to 12 months — if it states the frequency and period.
GFE ISSUED THU AUG 27, 2026 · PERIOD: SEP 1, 2026 – FEB 28, 2027
| Service | CPT | Qty | Expected charge |
|---|---|---|---|
| Diagnostic evaluation | 90791 | 1 | $180.00 |
| Psychotherapy, 55 min | 90837 | 24 | $3,600.00 |
| Family session, 50 min | 90847 | 4 | $680.00 |
| Total expected charges | $4,460.00 | ||
The full document also carries the client's name and DOB, the therapist's NPI and TIN, the office address, the diagnosis code once one exists, and the four disclaimers.
Where the $400 line sits
Total billed for the period stays under $4,860? No dispute right. Client needs 30 sessions instead of 24? That extra $900 crosses the threshold — issue an updated GFE before the extra sessions, and the new estimate controls.
Common miss
Raising your rate mid-period without a new estimate. The old GFE stands until you issue a revision no later than 1 business day before the next session at the new rate.
Therapist and Mental Health FAQ
Mental health providers file more GFE questions than any other specialty — recurring care, self-pay-heavy caseloads, and privacy-driven insurance opt-outs all collide here. The short answers:
Related reading for behavioral health practices: psychotherapy notes vs. progress notes and the minimum necessary rule.
Quick Reference
The whole rule on one card — screenshot this for your front desk.
GOOD FAITH ESTIMATE — CHEAT SHEET (AUG 2026)
- Regulation
- 45 CFR § 149.610 (GFE) / § 149.620 (disputes)
- Who gets one
- Uninsured patients + insured patients not billing their plan
- Deadline
- 1 business day (booked 3-9 days out) / 3 business days (10+ days out or on request)
- Changed charges
- New GFE no later than 1 business day before service
- Recurring care
- One GFE may cover up to 12 months; state frequency and period
- Dispute trigger
- Bill ≥ $400 over the GFE total; filed within 120 days; $25 fee
- Co-provider bundling
- Enforcement discretion since Dec 2022 — still paused (Aug 2026)
- Penalty ceiling
- Up to $10,000 per violation (PHSA § 2799B-4); waived if unknowing + refunded
- Retention
- Provide copies of GFEs issued within the past 6 years
Make it operational: generate estimates with the GFE generator, add the self-pay question to your intake form, and train schedulers on the deadlines alongside your annual HIPAA training. For insured patients on Medicare, the parallel notice is the Advance Beneficiary Notice.
Related Tools & Guides
Good Faith Estimate Generator
Build a printable GFE with CPT codes, expected charges, and every required disclaimer.
Patient Bill of Rights
Patient protections under HIPAA and the No Surprises Act, explained.
Advance Beneficiary Notice Guide
The Medicare cost-notice rule that runs alongside the GFE for insured patients.
Patient Intake Form Template
Add the GFE notice and self-pay election to your intake packet.
Psychotherapy Notes vs. Progress Notes
Documentation rules for the therapists most affected by GFE requirements.