"Good Faith Estimate for Health Care Items and Services" Under the No Surprises Act
Under Section 2799B-6 of the Public Health Service Act and its implementing regulations, health care providers are required to provide a good faith estimate of expected charges for services to individuals who are not enrolled in a group health plan or group or individual health insurance coverage, or a Federal health care program, or a Federal Employees Health Benefits (FEHB) program health benefits plan (uninsured individuals or not seeking to file a claim with their group health plan, health insurance coverage, or FEHB health benefits plan (self-pay individuals) in writing (and may also provide it orally, if an uninsured (or self-pay) individual requests a good faith estimate in a method other than paper or electronically), upon request or at the time of scheduling health care items and services.
A good faith estimate must be provided within 3 business days upon request. Information regarding scheduled items and services must be furnished within 1 business day of scheduling an item or service to be provided in at least 3 business days, and within 3 business days of scheduling an item or service to be provided in at least 10 days.
DISCLAIMER
This Good Faith Estimate shows the cost of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, and your bill is $400 or more for any provider than your Good Faith Estimate for that provider, federal law allows you to dispute the bill.
The Good Faith Estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers identified in the Good Faith Estimate.
If you are billed for more than this Good Faith Estimate, you may have the right to dispute the bill.
You may contact the health care provider to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
You may also start a dispute resolution process with the U.S. Dept of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
If you dispute your bill, the provider cannot move the bill for the disputed item or service into collection or threaten to do so, or if the bill has already moved into collection, the provider has to cease collection efforts. The provider must also suspend the accrual of any late fees on unpaid bill amounts until after the dispute resolution process has concluded. The provider or facility cannot take or threaten to take any retributive action against you for disputing your bill.
There is a $25 fee to use the dispute process. If the Selected Dispute Resolution (SDR) entity reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate, deducted by the $25 fee. If the SDR entity disagrees with you and agrees with the health care provider, you will have to pay the higher amount.
To learn more information, ask questions or get a form to start the process, go to www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gove or call 1-800-985-3059.
PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to: (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entity's compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider.