What must be on a Good Faith Estimate, and when it has to be issued

The obligation practices fail quietly

The Good Faith Estimate reaches every health care setting, including the solo practice with one administrator. It is triggered by something as ordinary as scheduling a patient who is uninsured, or insured but not using their benefits for this service. There is no software that produces one by default, no payer chasing it, and no remittance that shows it was missed — so it gets done from a half-remembered template and nobody finds out what was wrong with it until somebody disputes a bill.

What the regulation requires on it

Under 45 CFR 149.610(c)(1): the patient’s name and date of birth; a description of the primary item or service in clear and understandable language; an itemized list of items or services grouped by each provider or facility; applicable diagnosis codes, expected service codes and expected charges; the name, National Provider Identifier and Tax Identification Number of each provider; and a list of items or services the provider anticipates will require separate scheduling.

Then four notices, which are the part templates most often lose: that there may be additional items or services not reflected in the estimate; that the actual items, services or charges may differ from it; that the individual has a right to initiate the patient-provider dispute resolution process; and that the estimate is not a contract.

One honest caveat. The published list we read has a gap in its numbering between (vi) and (viii). We have not filled it with something plausible, and neither should any template you use — read the section.

The three deadlines

Under 149.610(b)(1)(vi): where the service is scheduled at least three business days ahead, the estimate is due within one business day of scheduling. Where it is scheduled at least ten business days ahead, within three business days. And where an uninsured or self-pay individual simply asks for one, within three business days of the request — whether or not they ever book anything.

The part that is not paperwork

An estimate that is wrong in the patient’s favour is a conversation; an estimate that is substantially below the final bill is a dispute the patient has an explicit right to initiate. So the quality of the estimate depends on things upstream of the document: whether eligibility was actually checked, whether the codes on the estimate are the codes that will be billed, and whether the self-pay balance was discussed before the visit rather than chased for ninety days after it.

A template you can reuse

We built a free generator that carries every element and all four notices, and produces a template rather than a finished document — the patient name and date of birth stay as marked placeholders, because this site does not accept patient information on any page. A practice issuing hundreds of these needs a correct template far more than it needs one completed estimate.