Good Faith Estimate Generator

Overview

The No Surprises Act requires healthcare providers to give uninsured or self-pay patients a Good Faith Estimate (GFE) of expected charges before scheduled services. This skill provides the framework to generate compliant GFEs.

Legal Requirement

NO SURPRISES ACT - 45 CFR § 149.610
Effective January 1, 2022

APPLIES TO:
- Uninsured individuals (no health coverage)
- Self-pay individuals (choosing not to use insurance)

REQUIRED:
- Good Faith Estimate of expected charges
- Provided upon scheduling OR upon request
- Within specified timeframes

Who Must Receive a GFE

Timing Requirements

Scheduled Services

Upon Request

Timeline Example

SCENARIO: Patient schedules appointment on Monday for Friday visit

Monday: Service scheduled (4 business days before)
Tuesday: GFE must be provided (within 1 business day)
Friday: Service rendered

SCENARIO: Patient schedules appointment Monday for Wednesday visit

Monday: Service scheduled (2 business days before)
Thursday: GFE must be provided (within 3 business days)
Wednesday: Service already rendered
→ Provide GFE as soon as practicable, even if after scheduling

Required GFE Content

Mandatory Elements (45 CFR § 149.610)

GOOD FAITH ESTIMATE CONTENT REQUIREMENTS
────────────────────────────────────────

PATIENT INFORMATION:
□ Patient name
□ Date of birth
□ Address
□ Contact information (phone/email)

PROVIDER/FACILITY INFORMATION:
□ Provider/facility name
□ National Provider Identifier (NPI)
□ Tax Identification Number (TIN)
□ Service location address
□ Contact information

SERVICE INFORMATION:
□ Description of primary service/item
□ Diagnosis codes (ICD-10) if applicable
□ Service/procedure codes (CPT/HCPCS)
□ Expected date of service
□ Expected service location

COST INFORMATION:
□ Itemized list of expected charges
□ Expected charge for each item/service
□ TOTAL expected charges

ADDITIONAL REQUIRED STATEMENTS:
□ Disclaimer that estimate may change
□ Patient dispute rights information
□ Instructions for obtaining itemized receipt

GFE Template

═══════════════════════════════════════════════════════════════
                    GOOD FAITH ESTIMATE
          For Uninsured or Self-Pay Patients
═══════════════════════════════════════════════════════════════

DATE OF ESTIMATE: {date}

PATIENT INFORMATION
───────────────────
Name: {patient_name}
Date of Birth: {dob}
Address: {address}
Phone: {phone}
Email: {email}

PROVIDER/FACILITY INFORMATION
─────────────────────────────
Provider Name: {provider_name}
Facility Name: {facility_name}
NPI: {npi}
TIN: {tin}
Service Location: {service_address}
Contact: {provider_phone}

SCHEDULED SERVICE
─────────────────
Expected Date: {service_date}
Primary Service: {service_description}
Diagnosis: {icd_10_code} - {diagnosis_description}

ESTIMATED CHARGES
─────────────────
┌────────────────────────────────────────┬──────────────────┐
│ Service                                │ Estimated Charge │
├────────────────────────────────────────┼──────────────────┤
│ {cpt_code} - {service_description}     │ ${amount}        │
│ {cpt_code} - {service_description}     │ ${amount}        │
│ {cpt_code} - {service_description}     │ ${amount}        │
├────────────────────────────────────────┼──────────────────┤
│ TOTAL ESTIMATED CHARGES                │ ${total}         │
└────────────────────────────────────────┴──────────────────┘

IMPORTANT INFORMATION
─────────────────────

This Good Faith Estimate shows the estimated costs of items and 
services that are reasonably expected for your healthcare needs 
for the item or service listed above. 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 you are billed for more than this Good Faith Estimate, you 
may have the right to dispute the bill.

YOUR RIGHTS:
• You have the right to receive this Good Faith Estimate in 
  writing before your scheduled service.
  
• If you receive a bill that is at least $400 more than your 
  Good Faith Estimate, you may dispute the bill.
  
• You may start a dispute resolution process with the U.S. 
  Department of Health and Human Services (HHS).

• Make sure to save a copy of this Good Faith Estimate.

For questions or more information about your right to a Good 
Faith Estimate, visit www.cms.gov/nosurprises or call [phone].

═══════════════════════════════════════════════════════════════
         Keep this estimate for your records
═══════════════════════════════════════════════════════════════

Multi-Provider Situations

Convening vs. Co-Provider

Convening Provider Workflow

PATIENT SCHEDULES SERVICE
         │
         ▼
┌────────────────────────────┐
│ Identify co-providers      │
│ who will provide items/    │
│ services                   │
└────────────┬───────────────┘
             │
             ▼
┌────────────────────────────┐
│ Request expected charges   │
│ from each co-provider      │
└────────────┬───────────────┘
             │
             ▼
┌────────────────────────────┐
│ Compile into single GFE    │
│ with all expected charges  │
└────────────┬───────────────┘
             │
             ▼
┌────────────────────────────┐
│ Provide consolidated GFE   │
│ to patient                 │
└────────────────────────────┘

Single Service, Multiple Providers Example

SCENARIO: Outpatient surgery

CONVENING PROVIDER: Surgeon
CO-PROVIDERS:
- Anesthesiologist
- Facility/Hospital
- Lab services
- Pathology (if applicable)

CONSOLIDATED GFE INCLUDES:
┌──────────────────────────┬──────────────────┐
│ Service                  │ Estimated Charge │
├──────────────────────────┼──────────────────┤
│ Surgeon fee              │ $2,500           │
│ Anesthesia               │ $800             │
│ Facility fee             │ $4,000           │
│ Lab work                 │ $150             │
│ Pathology                │ $300             │
├──────────────────────────┼──────────────────┤
│ TOTAL                    │ $7,750           │
└──────────────────────────┴──────────────────┘

Common Service GFE Templates

Office Visit

SERVICE: Office Visit - Established Patient
CPT: 99214
Diagnosis: {ICD-10}

ESTIMATED CHARGES:
- Office visit (99214): $175
- {Additional services if known}
─────────────────────────────
TOTAL: $175

Minor Procedure

SERVICE: {Procedure Name}
CPT: {code}
Diagnosis: {ICD-10}

ESTIMATED CHARGES:
- Procedure ({cpt}): ${amount}
- Office visit if applicable (99213): $125
- Supplies/materials: ${amount}
─────────────────────────────
TOTAL: ${total}

Imaging

SERVICE: {Imaging Study}
CPT: {code}
Diagnosis: {ICD-10}

ESTIMATED CHARGES:
- Technical component ({cpt}-TC): ${amount}
- Professional component ({cpt}-26): ${amount}
OR
- Global fee ({cpt}): ${amount}
─────────────────────────────
TOTAL: ${total}

Lab Work

SERVICE: Laboratory Services
CPT: {code(s)}
Diagnosis: {ICD-10}

ESTIMATED CHARGES:
- {test name} ({cpt}): ${amount}
- {test name} ({cpt}): ${amount}
- {test name} ({cpt}): ${amount}
- Specimen collection (36415): $15
─────────────────────────────
TOTAL: ${total}

Dispute Rights

Patient Dispute Process

When patient may dispute:

• Final bill exceeds GFE by $400 or more

DISPUTE TIMELINE:
1. Patient receives bill exceeding GFE by $400+
2. Patient initiates dispute within 120 days of bill
3. HHS-selected dispute resolution (SDR) entity reviews
4. SDR determines payment amount
5. Provider must accept SDR determination

Provider Responsibilities

Record Retention

GFE RETENTION REQUIREMENTS:
- Retain GFE as part of patient's medical record
- Provide copy to patient upon request
- Retention period: Follow medical record retention rules
  (typically 6-10 years depending on state)

Workflow Integration

Scheduling Process

PATIENT CALLS TO SCHEDULE
            │
            ▼
┌───────────────────────────┐
│ Ask: Using insurance?     │
│ □ Yes → Standard process  │
│ □ No → GFE required       │
└───────────┬───────────────┘
            │ (If No)
            ▼
┌───────────────────────────┐
│ Collect:                  │
│ - Service requested       │
│ - Expected date           │
│ - Patient demographics    │
└───────────┬───────────────┘
            │
            ▼
┌───────────────────────────┐
│ Generate GFE              │
│ (within timing rules)     │
└───────────┬───────────────┘
            │
            ▼
┌───────────────────────────┐
│ Deliver to patient        │
│ - Paper, email, portal    │
│ - Document delivery       │
└───────────────────────────┘

Documentation Checklist

□ Patient identified as uninsured/self-pay
□ GFE generated with all required elements
□ GFE delivered within required timeframe
□ Delivery method documented
□ Copy retained in patient record
□ Patient acknowledged receipt (if possible)

Resources

references/

• gfe-content-checklist.md — Full content requirement checklist
• timing-rules-reference.md — Detailed timing requirements
• dispute-process-guide.md — Patient dispute process details

scripts/

• gfe-generator.py — Generates GFE from inputs

assets/

• gfe-template.docx — Fillable GFE template
• gfe-spanish.docx — Spanish language template
• patient-rights-notice.pdf — Standalone rights notice