Good Faith Estimates (GFEs)

To be in compliance with the No Surprises Act (NSA) payers and providers must make two things available to members/patients. First, providers must make Good Faith Estimates (GFEs) available to patients. GFEs are designed to educate patients on the cost of upcoming items or services. The NSA defines items or services are as any individual item, service, or service package that could be provided to a patient for which the facility or provider has an established charge. Examples include supplies, procedures, and room and board. Basically, a GFE is an estimated cost for an upcoming item or service. Most importantly, the actual total cannot exceed $400 over the GFE amount.

As of January 1, 2021, GFEs are required in advance or upon request, electronically or on paper, to uninsured or self-pay individuals. Self-pay individuals are defined as insured individuals who have chosen to pay for specific items or services instead of filing a claim to the insurer for payment. 

GFEs must be delivered in language a patient can easily understand (defined as “plain language”) and contain the following:

Patient and Provider Information

  • Patient name and DOB
  • Description of the primary item or service in plain language
  • Itemized list of items or services, grouped by each provider or facility, reasonably expected to be provided for the primary item or service. And items or services reasonably expected to be furnished in conjunction with the primary item or service, for that period of care including:
    • Those items or services are reasonably expected to be furnished by the convening provider or facility (the provider or facility responsible for scheduling the service and creating the GFE), and
    • Those items or services expected to be furnished by co-providers or co-facilities (any provider or facility expected to furnish items or services in addition to the convening provider or facility)
  • Name, NPI, and TIN, of each provider or facility represented in the good faith estimate, and the state(s) and office or facility location(s) where the items or services are expected to be furnished

Item or Service Information

  • Expected charges for the items and services: The cash pay rate or rate established by a provider or facility for an uninsured or self-pay individual
  • A list of items or services that the convening provider or facility anticipates will require separate scheduling and is expected to occur before or following the primary item or service is furnished
    • Co-providers must then assign any additional items or services so all items and services are included on a single GFE
    • Due to the complexity of coordinating between convening and co-providers, The Centers for Medicare and Medicaid Services (CMS) will not enforce the inclusion of all providers’ items and services on one GFE until further notice
  • Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service
  • List of predetermined disclaimers provided by CMS

Time Limitations 

NSA has outlined specific time limits for the delivery of a GFE. If an item or service is scheduled less than three days in advance, the GFE is due within one business day after the items or services are scheduled. Items or services scheduled at least 10 days in advance require a GFE within three business days. GFEs are considered legal documents and must stay a part of the individual’s file for six years following their creation date.

Insured individuals who plan to submit items or services to their insurance provider can also request GFEs. In that scenario, the expected charge populated on the GFE shows the amount the provider or facility would expect to charge if the provider or facility intended to bill a plan or issuer directly for items or services. GFEs provided to insured individuals are subsequently sent to providers to create an Advanced Explanation of Benefits (AEOB).