Good Faith Estimates for Uninsured Patients

Before the No Surprises Act took effect in 2022, an uninsured or self-pay patient scheduling a procedure had no federal right to know what it would cost. They might receive a vague verbal estimate or nothing at all, and the final bill could be far higher than any informal number they were given. The No Surprises Act changed this by creating a mandatory good-faith estimate process: providers must give uninsured and self-pay patients a written, itemized cost estimate before scheduled services, and there is a dispute process when the final bill substantially exceeds it.

For the broader picture of what the No Surprises Act covers, visit the No Surprises Act guide.

Who qualifies for a good-faith estimate

The good-faith estimate requirement applies to two groups of patients:

Uninsured patients — those who have no health coverage at the time a service is scheduled.

Self-pay patients — insured individuals who choose not to use their insurance for a specific service. This could be someone who prefers not to have a service appear in their insurance records, someone whose deductible is so high that insurance provides no immediate benefit, or someone who finds the self-pay rate lower than their cost-sharing obligation.

If you are insured and plan to use your insurance, the good-faith estimate rules in the No Surprises Act do not apply to you in the same way. Insurers are separately required to offer price transparency tools under other federal rules, but those operate differently.

The estimate requirement applies to providers and facilities that bill Medicare or Medicaid — which includes virtually all licensed physicians, hospitals, ambulatory surgery centers, imaging centers, and labs.

What the estimate must contain

A compliant good-faith estimate is not a ballpark number — it must be an itemized written document. Federal rules specify that it must include:

• The name and contact information of the scheduling provider or facility
• An itemized list of expected services, with billing codes (CPT, HCPCS, NDC, or ICD-10 codes as applicable)
• The expected charges for each item and service
• The names and NPI or tax ID numbers of any other providers or facilities expected to participate in the service and bill you separately
• A good-faith estimate of the charges from each of those other providers
• A statement of your right to dispute a final bill that substantially exceeds the estimate

The estimate must be clear, written in plain language, and delivered in a format you can retain — either printed or in a durable electronic form you can save.

Timing: when you must receive the estimate

The timing rules depend on how far in advance the service is scheduled:

Scheduling lead time	When estimate must be provided
Service scheduled 10+ business days in advance	Within 3 business days of scheduling
Service scheduled 3–9 business days in advance	No later than 1 business day before the service
Estimate requested without scheduling	Within 3 business days of request

These are minimum requirements — a provider may give you the estimate earlier. If you request an estimate at the time of scheduling and the provider declines or delays beyond the required window, you have grounds to file a complaint with CMS.

What to do if your final bill exceeds the estimate by more than $400

The No Surprises Act created the Patient-Provider Dispute Resolution (PPDR) process specifically for situations where the final bill is substantially higher than the good-faith estimate. The threshold that triggers your right to use this process is $400 above the estimate total.

Steps to initiate a dispute:

1. Receive the final itemized bill from the provider. Compare it line by line to your good-faith estimate.
2. Calculate the difference between the bill total and the estimate total. If the difference exceeds $400, you qualify for PPDR.
3. Contact the provider first. Some overages result from simple billing errors or added services that were not explained to you. Ask the provider to justify each item that was not on the estimate.
4. Initiate the PPDR process through the federal dispute portal if the provider will not correct the bill. You have 120 days from the date of the bill to initiate the dispute.
5. Pay the estimate amount or a reasonable good-faith amount while the dispute is pending. You are not required to pay the full disputed amount before the process concludes.
6. Receive the determination. An independent dispute resolution entity will review the estimate and the final bill and determine a fair payment amount.

Documents and terms you’ll see

When navigating the good-faith estimate process, you will encounter these terms on provider documents and federal notices:

• Good-faith estimate — the written pre-service cost document the provider must deliver; it itemizes expected charges by service and provider
• Self-pay — choosing to pay out of pocket rather than using insurance; self-pay patients have the same right to a good-faith estimate as uninsured patients
• Uninsured — a patient with no coverage at the time of the scheduled service; one of the two categories the good-faith estimate requirement serves
• Patient-Provider Dispute Resolution (PPDR) — the federal arbitration process for contesting a final bill that exceeds the estimate by more than $400; initiated through a CMS portal

Limits of the good-faith estimate protection

Understanding what the good-faith estimate does not do helps you plan:

It is not a price cap. If additional services are legitimately required during your care — a lab finding that requires an extra test, a complication that demands additional treatment — those charges are not automatically subject to dispute just because they were not in the estimate. The $400 threshold applies to the overall difference, including unexpected but medically justified services.

It does not apply to emergency care. Good-faith estimates require scheduled services. Emergencies cannot be anticipated and are not subject to this requirement.

It does not apply to insured patients using their insurance. If you present your insurance and ask the provider to bill it, the good-faith estimate rules do not apply. Your insurer’s coverage terms govern what you pay.

The $400 threshold is per estimate, not per service line. A bill that is $50 over on each of ten service lines totals $500 over, which crosses the threshold. A bill that is $390 over on one item does not trigger PPDR even though it is a significant additional charge.

Comparing estimates from multiple providers before scheduling a procedure is one of the most practical uses of this right. The PPDR process is a backstop for when estimates prove inaccurate; shopping before scheduling is the first line of protection.