Good Faith Estimate requirements for uninsured and self-pay patients

What is a Good Faith Estimate?

A Good Faith Estimate is a notification of expected charges for a scheduled or requested item or service, including items or services reasonably expected to be provided with it. That is how 45 CFR 149.610(a)(2)(vi) defines it.

The estimate uses the cash-pay rate or the rate the provider or facility has set for uninsured and self-pay patients, with any discount for those patients already applied. The regulation calls this the expected charge.

Who needs a Good Faith Estimate: uninsured or self-pay patients?

A patient gets a GFE if they are uninsured or self-pay for the item or service. Under 45 CFR 149.610(a)(2)(xiii), that means someone with no benefits for it under a group health plan, individual or group insurance, a federal health care program or a Federal Employees Health Benefits plan.

Do insured patients who pay cash get a GFE?

Yes, if they choose not to use their insurance for that service. Under 45 CFR 149.610(b)(1)(ii), the convening provider must ask an insured patient whether they want a claim submitted to the plan for the primary item or service, and a patient who says no is treated as self-pay.

What must the front desk ask and display?

The convening provider or facility must ask two questions, per 45 CFR 149.610(b)(1)(i) and (ii): is the patient enrolled in a plan or coverage, and if so, do they want a claim submitted to it. It must then tell every uninsured or self-pay patient that a GFE is available.

That notice has three delivery rules under 45 CFR 149.610(b)(1)(iii). It must be displayed on the website where a public search engine can find it, in the office and where scheduling or cost questions happen. It must also be given orally when scheduling or when cost questions come up. And it must be offered in accessible formats and in the languages the patients speak. CMS lists model notices on its No Surprises Act overview page.

A cost question counts as a request. Under 45 CFR 149.610(b)(1)(iv), any discussion or inquiry about potential costs of items or services under consideration is treated as a request for a GFE. A scheduler who answers a price question with a verbal number has probably started a 3-business-day clock.

When must a GFE be given to a patient?

The deadline depends on how far ahead the care is scheduled, or on whether the patient asked for the estimate. The three timeframes are set in 45 CFR 149.610(b)(1)(vi). All of them count business days.

Care scheduled fewer than 3 business days ahead is a different case. CMS FAQs Part 5 say a provider is not required to give a GFE to a patient who schedules fewer than 3 business days before the date of service, such as for walk-in appointments and emergencies. A GFE given anyway is voluntary.

Do emergency services need a GFE?

Generally no. CMS FAQs Part 1 note that urgent, emergent trauma and emergency services are not typically scheduled in advance, so they may not be included. The same FAQ adds that if such care is scheduled at least 3 days in advance, a provider or facility must give a GFE.

What if the plan of care changes before the visit?

A new estimate is required. Under 45 CFR 149.610(b)(1)(vii), if the convening provider, facility, a co-provider or a co-facility anticipates or is told of a change to the scope of the estimate, a new GFE must reach the patient no later than 1 business day before the service. Changes it lists include expected charges, items, services, frequency, duration, providers and facilities.

What must a GFE include?

A GFE must show who is billing what, for which service, at what expected charge. The required list is in 45 CFR 149.610(c)(1), and the items below are the ones that most often come back incomplete when a hospital builds its own template.

Diagnosis codes come from the ICD code set, which means ICD-10-CM. Under 45 CFR 149.610(a)(2)(xii), service codes can be CPT, HCPCS, MS-DRG or National Drug Codes, depending on the item. A hospital estimate for an inpatient stay and a clinic estimate for a procedure will not use the same mix.

Can providers use a template GFE?

Yes. CMS publishes a Model Notice: Good Faith Estimate for Health Care Items and Services, and an abbreviated version for no-cost items, on its No Surprises Act overview page. The regulation does not require a particular form, only the content in 45 CFR 149.610(c)(1).

How must the estimate be delivered?

In writing, on paper or electronically, in the format the patient asks for. Under 45 CFR 149.610(e)(1), an electronic GFE must be one the patient can both save and print, and it must be written in clear language the average patient can understand.

A phone request does not remove the written step. Under 45 CFR 149.610(e)(2), the provider may give the information orally if the patient asks that way, but must still issue the GFE in written form to meet the requirement.

What are convening providers and co-providers?

The convening provider or facility is the one that gets the patient's request and is, or would be, responsible for scheduling the primary service. A co-provider or co-facility is any other provider or facility that furnishes items or services customarily provided with that primary service. Both definitions are in 45 CFR 149.610(a)(2)(ii) and (iii).

What does the convening provider ask of co-providers?

A data request within 1 business day. Under 45 CFR 149.610(b)(1)(v), once the patient requests an estimate or schedules the primary service, the convening provider must contact every co-provider and co-facility reasonably expected to take part, no later than 1 business day after the scheduling or request. The request must include the date the information has to come back.

What does a co-provider send?

Under 45 CFR 149.610(d)(1), co-provider information must include the patient name and date of birth, an itemized list of the co-provider's expected items or services, diagnosis codes, expected service codes and expected charges, the co-provider's name, NPIs and TINs with locations, and the not-a-contract disclaimer.

When does a co-provider become a convening provider?

When the patient deals with it directly. Under 45 CFR 149.610(b)(2)(iv), if a patient separately schedules with or requests an estimate from a provider that would otherwise be a co-provider, that provider is treated as a convening provider and must meet every convening requirement for that service.

Is CMS enforcing co-provider data in the estimate?

No. CMS FAQs Part 3, dated December 2, 2022, say HHS is extending enforcement discretion, pending future rulemaking, for situations where GFEs for uninsured or self-pay patients do not include expected charges from co-providers or co-facilities. It also says any rulemaking that fully implements the requirement will include a prospective applicability date.

The regulation itself has not changed. The text of 45 CFR 149.610 still requires co-provider information, and CMS lists the Part 3 FAQ among its current guidance on its overview page, last modified October 14, 2026. No later CMS document ends that discretion.

How do hospitals handle GFEs across departments?

A hospital usually acts as the convening facility, with its own departments and contracted groups as co-providers. The scheduling department that books the primary service owns the estimate, and the departments that add items must feed it charge and code data inside the 1-business-day window.

What about providers who do not expect to bill the patient?

CMS allows an abbreviated GFE for providers who know in advance they will not bill the patient. This is an enforcement position described in CMS FAQs Part 4, dated December 27, 2022, not a rule in 45 CFR 149.610.

Three conditions apply under that FAQ. The provider gives the patient an abbreviated GFE. It does not bill patients who receive one. And no items in the abbreviated GFE are expected to come from co-providers or co-facilities.

How long must GFEs be kept?

A GFE becomes part of the patient's medical record and must be maintained the same way. That rule is in 45 CFR 149.610(f)(1).

Convening providers must also be able to produce older ones. Under the same paragraph, they must give a copy of any GFE issued within the last 6 years to an uninsured or self-pay patient who asks for it.

What happens if the estimate has a mistake?

Fix it promptly. Under 45 CFR 149.610(f)(3), a provider does not fail to comply solely because it made an error or omission despite good faith and reasonable due diligence, as long as it corrects the information as soon as practicable.

What happens if the final bill is much higher than the GFE?

The patient can start the federal patient-provider dispute resolution process. Under 45 CFR 149.620(a)(2)(ii), a bill is substantially in excess of the estimate when the total billed charges are at least $400 more than the total expected charges listed for that provider or facility.

What does the Advanced EOB have to do with the GFE?

The Advanced Explanation of Benefits (AEOB) is the insurer-side counterpart for insured patients, and the related insured-patient GFE is not currently being enforced. CMS FAQs Part 1 say HHS has not issued rulemaking for patients who have coverage and want a claim submitted, and will defer enforcement of the requirement to provide GFE information for those patients until rulemaking is adopted and applicable.

CMS FAQs Part 2, dated April 5, 2022, repeat the position: HHS will not enforce against providers and facilities that do not send GFEs to plans and issuers for individuals who are not uninsured or self-pay at the time of scheduling or request.

The latest CMS statement we could open is the Progress Toward AEOB Rulemaking update of December 13, 2024. It says the Departments and the Office of Personnel Management are working toward rulemaking and describes consumer research and data-standard work, not a final rule. Check the CMS overview page before relying on this, because rulemaking could change the position.

How we handle Good Faith Estimates

We build the estimate workflow around your scheduling and charge data, so the 1-business-day and 3-business-day clocks are tracked from the moment care is booked or a price question is asked. Our team is offshore plus our registered office in Richmond, KY, and works inside your existing systems.

Our work covers the insured-or-self-pay screening question, co-provider data requests with due dates, itemized estimate assembly at your self-pay rates, delivery in the patient's requested format and filing in the record. When a patient disputes a bill, we gather the estimate, the bill and the supporting documents so nothing is missing.

This sits next to our patient billing services and our out-of-network billing and IDR work. To talk through your estimate process, book a call.