Good Faith Estimates for Self-Pay Patients

A Good Faith Estimate (GFE) is a written estimate of the expected charges for scheduled health care items or services, required by the No Surprises Act for patients who are uninsured or who choose to self-pay rather than use their insurance. Providers and facilities must furnish the estimate within specified timeframes based on when the service is scheduled, and patients may dispute bills that exceed the estimate by a defined threshold.

Before the NSA, self-pay patients often had no way to know what a service would cost until they received the bill. The GFE requirement addresses that gap by giving patients a written, itemized estimate before the service is furnished, and by creating a dispute resolution mechanism if the final bill exceeds the estimate beyond a defined margin. The requirement applies to scheduled services, not to emergency care.

Identify self-pay patients before scheduling. The GFE requirement applies to patients who are uninsured or who notify the provider that they intend to self-pay. Capturing this status at scheduling, not at check-out, is what triggers the estimate obligation on time.

Include all expected charges in the estimate. A GFE must include the expected billing codes and diagnoses, the expected charges for each, and the names and NPIs of providers and facilities involved. A partial estimate is not a compliant estimate.

Furnish the estimate within the required timeframes. The timeframes are tied to when the service is scheduled: a service scheduled three or more business days in advance requires an estimate within one business day of scheduling; a service scheduled ten or more business days in advance requires an estimate within three business days. The timeframe is prescribed, not flexible.

Operate the dispute resolution process. If the final bill exceeds the GFE by more than a defined threshold, the patient may invoke a patient-provider dispute resolution process. The provider must be prepared to participate and to justify the charges, or to adjust the bill.

Retain documentation. The GFE, the delivery confirmation, and any dispute resolution correspondence should be retained as compliance records. CMS can request these during an investigation.

• A workflow that flags self-pay status at scheduling and triggers the GFE process.
• A template that includes all required elements (codes, diagnoses, charges, provider NPIs).
• A timer that tracks the scheduling-to-estimate delivery window.
• A dispute resolution workflow with defined thresholds and escalation paths.
• A documentation retention policy for GFEs and related correspondence.

1. 01

   Confirm the patient is uninsured or self-pay

   At the point of scheduling, determine whether the patient is uninsured or has stated they will self-pay. This triggers the GFE requirement. A patient who has insurance but has not stated they will self-pay does not require a GFE under the NSA.
2. 02

   Compile the expected charges

   List the expected billing codes, diagnosis codes, and expected charges for the scheduled service, including any co-provider or facility charges the patient can expect. Include provider and facility NPIs.
3. 03

   Deliver the estimate within the required timeframe

   If the service is scheduled at least three business days in advance, deliver the GFE within one business day of scheduling. If scheduled at least ten business days in advance, deliver within three business days. For services scheduled less than three business days in advance, the GFE is due on the date of scheduling or as soon as practicable.
4. 04

   Retain the estimate and delivery confirmation

   Keep a copy of the GFE and confirmation that it was delivered to the patient. These records are the provider's evidence of compliance if the patient later disputes the bill or CMS investigates.
5. 05

   Operate the dispute resolution process if invoked

   If the final bill exceeds the GFE by more than the defined threshold, the patient may invoke the patient-provider dispute resolution process. Participate in good faith, justify the charges or adjust the bill, and document the outcome.

Review the control on a fixed cadence and after a material policy, payer, system, staffing, or workflow change. Compare the current process with its documented design, sample the evidence it produces, and record exceptions separately from completed routine work. A control that exists only in a policy but leaves no observable evidence cannot be evaluated reliably.

Use findings to change the upstream process, not merely to clear the current queue. Assign one owner, one next action, and one follow-up date. Preserve the definition and baseline used for the review so a later result can be compared without changing the measurement after the fact.