What a good faith estimate is
A good faith estimate is a written list of the items and services a doctor, hospital or other licensed provider expects to furnish, with the expected charge for each, given to a patient who will not be billing insurance. The federal No Surprises Act requires it, and the detailed rules are in 45 CFR 149.610.[1] It can arrive on paper or electronically, it becomes part of your medical record, and you can ask for a copy of any estimate issued to you in the last six years.[1]
The estimate is not a contract, and it does not oblige you to use the providers it names. Its value is that it fixes a reference point: if the final bill lands far above it, you have a formal, low-cost way to challenge the difference. That makes it the cheapest piece of paper in self-pay health care, and the one most patients never ask for.
Who gets a No Surprises Act good faith estimate
You are entitled to a No Surprises Act good faith estimate if you have no coverage for the service, or you have coverage but choose not to file a claim for it.[1] The second group matters more than people think: someone with a high-deductible plan who decides to pay cash for an MRI qualifies, and so does someone whose medical plan simply has no benefit for the service in question.
People enrolled in Medicare, Medicaid or another federal health program are not "uninsured" for services that program covers. Emergency care is also outside the rule in practice, because the estimate is tied to care that is scheduled or requested in advance; for what an unplanned visit costs, see ER visit cost without insurance.
The rule reaches any licensed health care provider acting within the scope of its license and any licensed facility, which the regulation lists as including hospitals and hospital outpatient departments, surgery centers, community health centers, laboratories and imaging centers.[1]
When the estimate is due
A provider has 1 to 3 business days to send a good faith estimate, depending on how far ahead you book. Care booked only 0 to 2 business days out carries no right to one.[3]
| Situation | Deadline for the written estimate |
|---|---|
| Scheduled 0–2 business days ahead | No right to an estimate |
| Scheduled 3–9 business days ahead | Within 1 business day of scheduling |
| Scheduled 10 or more business days ahead | Within 3 business days of scheduling |
| You ask what it will cost (no appointment yet) | Within 3 business days of your request |
| The provider learns the plan of care has changed | A new estimate, at least 1 business day before the service |
| Recurring care (for example a course of therapy) | One estimate may cover up to 12 months |
Two details make the right easy to use. First, the regulation treats any conversation about cost as a request, so asking "what will this cost me?" at the front desk starts the 3-day clock.[1] Second, providers must tell you the right exists: in writing on their website and in the office where scheduling happens, and out loud when you book or ask about prices.[1]
What a good faith estimate must include
A complete good faith estimate lists your name, the service, every expected item grouped by provider, the codes and the expected charge for each, and four required disclaimers. Use this checklist when one arrives; a missing line is worth asking about before the appointment, not after.[1]
| Must include | What to check |
|---|---|
| Your name and date of birth | Spelled the way the bill will be |
| A plain-language description of the main service, and its date if scheduled | It matches what your doctor ordered |
| An itemized list of expected items and services, grouped by provider or facility | Facility fee, professional fee, anesthesia, lab and imaging all appear |
| Diagnosis codes, service codes and the expected charge for each line | Service codes such as 72148 (MRI lower back) let you compare prices |
| Name, National Provider Identifier and Tax ID of each provider or facility, and where care happens | Who will actually send you a bill |
| Services the provider expects to be scheduled separately | Ask for their estimates too |
| Disclaimer: other services may be needed and are not included | Ask what those might be |
| Disclaimer: the figures are only an estimate | Standard wording |
| Disclaimer: your right to dispute a bill that is substantially higher | The $400 rule and where to file |
| Disclaimer: the estimate is not a contract and you need not use these providers | You can still shop elsewhere |
Expect gaps in one place. CMS says each estimate covers only one provider or facility, so a surgery or scan done in a hospital can produce separate estimates from the hospital and from the physicians who work there.[3] Ask each of them. For a hospital service, compare the estimate with the hospital's own posted cash price, which federal price transparency rules require it to publish.[5]
How to dispute a bill that is higher than the estimate
If a provider bills at least $400 more than its own estimate, you can start the federal patient-provider dispute process within 120 calendar days of the first bill.[2][4] The $400 test is applied to each provider or facility separately, not to the whole episode of care.[2]
| Step | Rule |
|---|---|
| Eligibility | Billed total at least $400 above that provider's estimate |
| Deadline | Postmarked within 120 calendar days of the first bill |
| Cost to you | $25 administrative fee; credited back if you win, half refunded by the provider if you settle |
| While it is pending | The provider may not send the disputed bill to collections or add late fees |
| Decision | From an independent reviewer, within 30 business days after it receives the provider's documents |
The reviewer decides as follows. If the provider cannot show credible information that the extra cost was needed and unforeseen, you owe the estimated amount; for a service that was never on the estimate, you owe nothing. If the provider can justify it, you owe the lower of the billed charge and the median amount health plans pay for the same service.[2] You can still pay the undisputed part and negotiate the rest: see how to negotiate medical bills for anchor prices to use.
A worked example: an MRI billed by two providers
Suppose you book an MRI of the lower back at a hospital outpatient department two weeks ahead. Using this site's typical self-pay price for that scan, $1,550, split between the hospital and the radiologist the way Medicare splits its own payment, the estimates might read:
| Provider | What they bill for | Estimate | Disputable if billed at least |
|---|---|---|---|
| Hospital | Facility fee for 72148 | $1,250 | $1,650 |
| Radiology group | Reading and report | $320 | $720 |
If the hospital's bill then arrives at $1,840, the hospital's part qualifies for dispute even though the radiologist billed exactly what it said. To see what an MRI should cost in your area before you book, use the MRI cost estimator; for any single procedure code, the Medicare fee schedule lookup shows the government rate to compare against.
Keep the paperwork together.To dispute, you need the estimate itself and the bill; CMS says to ask the provider for a new copy if you lose the estimate, and to file a complaint if you were never given one.[3]
Ways to use the estimate to pay less
A good faith estimate does more than protect you from a surprise; it is a shopping tool. Request estimates from two or three providers for the same service code and compare totals, not just the headline fee. Ask whether the estimate already reflects a cash or prompt-pay discount, and if it does not, ask for one in writing before the visit. If the total is still more than you can pay at once, compare an office payment plan with financing on the payment plan calculator, and check whether your income qualifies you for a sliding scale clinic discount instead.
Frequently asked questions
What is a good faith estimate?
It is a written estimate of the expected charges for scheduled or requested care, which providers must give uninsured and self-pay patients under the No Surprises Act. It lists each expected item, its codes and price, grouped by provider.[1]
Is a good faith estimate legally binding?
No. The estimate itself says it is not a contract. What it does is create a right: if the bill exceeds the estimate by $400 or more for one provider, you can use the federal dispute process, and the reviewer may hold the provider to the estimate.[2]
Can I get a No Surprises Act good faith estimate if I have insurance?
Yes, if you tell the provider you will not be filing a claim with your plan for that service. If you do use your insurance, different No Surprises Act protections apply instead.[1]
Do dentists and therapists have to give one?
The regulation's definition of provider is any health care provider acting within the scope of a state license, which on its face includes dentists, therapists and other licensed clinicians. Ask for the estimate in writing; see therapy without insurance for session prices to compare.
What if I never received an estimate?
Ask for one; any question about cost counts as a request. If you should have received one and did not, CMS asks you to submit a complaint. Without an estimate you cannot use the $400 dispute process.[3]
Sources
- 45 CFR 149.610: Requirements for provision of good faith estimates to uninsured (or self-pay) individuals
- 45 CFR 149.620: Requirements for the patient-provider dispute resolution process
- Good faith estimate guide (No Surprises Act, uninsured and self-pay patients)
- Dispute a medical bill
- 45 CFR Part 180: Hospital price transparency (standard charges, discounted cash price, shoppable services)