Understanding Good Faith Estimates
The No Surprises Act, which took effect on January 1, 2022, established important patient protections including your right to receive a Good Faith Estimate of expected healthcare costs. This page explains what this means for you and helps you understand the critical difference between true in-network care and self-pay arrangements.
What Is a Good Faith Estimate?
Your federally-protected right to know healthcare costs before receiving care
A Good Faith Estimate (GFE) is a written estimate of expected charges for healthcare items or services, based on information reasonably available at the time the estimate is created. Under federal law (specifically, Public Health Service Act § 2799B-6, codified in 45 CFR Part 149), healthcare providers must give you this estimate so you can understand and plan for your healthcare costs before receiving care.
The requirement exists because, historically, patients often had no way to know what their care would cost until after receiving a bill—sometimes weeks or months later. The No Surprises Act changed this by establishing cost transparency as a legal right, not just a courtesy.
It's important to understand what a GFE is and isn't: A Good Faith Estimate is not a bill and not a contract. It's based on information known at the time it's created, and it gives you a tool to compare costs and dispute significant discrepancies if your final bill is $400 or more higher than the estimate.
Key Facts About Good Faith Estimates
- Legal requirement since January 1, 2022: The No Surprises Act made GFEs mandatory for all healthcare providers and facilities operating under state licensure—including mental health therapists, psychologists, social workers, and counselors.
- Applies to telehealth too: The GFE requirement covers both in-person and telehealth/video therapy sessions.
- Must be provided in writing: Even if you request cost information verbally, providers must still furnish the GFE in written form for your records.
- Dispute rights included: If your final bill exceeds the GFE by $400 or more, you have the right to dispute the charges through a federal Patient-Provider Dispute Resolution (PPDR) process.
- Recurring services covered: For ongoing therapy, providers may issue one GFE covering up to 12 months of treatment, clearly describing the anticipated timeframe, frequency, and number of sessions.
What a GFE Must Include
A compliant Good Faith Estimate includes specific information required by federal regulation (45 CFR § 149.610):
- • Provider name, contact info, NPI, and Tax ID
- • Patient name and date of birth
- • Description of services (including CPT codes like 90837 for therapy)
- • Diagnosis codes if available
- • Expected charges per service and total estimated cost
- • For recurring therapy: timeframe, frequency, and number of sessions
- • Required disclaimers about dispute rights
When You're Entitled to a Good Faith Estimate
Understanding who qualifies for this protection
The GFE requirement applies specifically to "uninsured or self-pay" patients. However, this category is broader than many people realize. You are considered a self-pay patient—and entitled to a GFE—in any situation where you will be paying out-of-pocket rather than having your insurance billed directly.
You Are Entitled to a Good Faith Estimate If:
- ✓You don't have health insurance — Whether you've never had coverage, are between jobs, or lost coverage for any reason, you qualify for a GFE.
- ✓You choose not to use your insurance — Some patients prefer self-pay for privacy reasons, to avoid claims on their record, or because their deductible is very high. If you're paying out-of-pocket by choice, you're entitled to a GFE.
- ✓Your insurance doesn't cover the service — If your plan excludes certain types of therapy or you've exhausted your session limit, you become a self-pay patient for those services.
- ✓You're seeing an out-of-network provider — If the provider doesn't bill your insurance directly and you're paying the full fee upfront (even with a superbill for reimbursement), you qualify as self-pay.
- ✓You request one at any time — You can request a GFE for any scheduled or requested service, and providers must comply within required timeframes.
Critical Provider Requirement
Required Timeframes for Providing a GFE
Federal regulations specify exactly when providers must deliver a Good Faith Estimate based on how far in advance you schedule:
| Scheduling Scenario | GFE Delivery Deadline |
|---|---|
| Service scheduled 10+ business days ahead | Within 3 business days of scheduling |
| Service scheduled 3-9 business days ahead | Within 1 business day of scheduling |
| Service scheduled less than 3 business days ahead | No requirement (voluntary) |
| You request a GFE without scheduling | Within 3 business days of request |
Business days = Monday–Friday, excluding federal holidays
Why This Matters: In-Network vs Self-Pay
Understanding the difference is critical for your financial protection
One of the most important distinctions in healthcare billing is the difference between being a true in-network patient and being a self-pay patient who submits their own claims. These are fundamentally different situations with different costs, protections, and responsibilities—yet they are often confused or conflated.
Understanding this distinction can save you hundreds or even thousands of dollars and protect you from unexpected bills. The No Surprises Act provides certain balance billing protections, but these generally do not apply to routine outpatient therapy when you voluntarily choose an out-of-network provider.
| Aspect | True In-Network Care | Self-Pay with Superbill |
|---|---|---|
| Provider relationship | Signed contract with your plan | No contract with your plan |
| Who bills insurance | Provider bills directly | YOU submit claims yourself |
| What you pay upfront | Copay/coinsurance only | Full session fee |
| Rate applied | Negotiated contracted rate | Provider sets own fee |
| Reimbursement certainty | Guaranteed at contracted rate | Based on plan's UCR—not guaranteed |
| Balance billing protection | Yes, protected by law | No protection—you pay the difference |
| Good Faith Estimate | Not required (costs known) | Legally required |
What "UCR" Means for Your Reimbursement
When you submit out-of-network claims, your insurance doesn't pay based on what your provider actually charges. Instead, they use "Usual, Customary, and Reasonable" (UCR) rates—determined by the plan's own data or commercial databases. These UCR amounts are often significantly lower than what providers charge, leaving you responsible for the difference (this is called "balance billing").
Higher Deductibles Apply
Most plans have separate, higher deductibles for out-of-network care. Even if you've met your in-network deductible, you may need to meet an entirely separate out-of-network deductible before receiving any reimbursement for self-pay claims.
Real-World Cost Example
Scenario: A 60-minute therapy session. Provider fee: $175.
In-Network
- • You pay: $30 copay at session
- • Provider bills insurance directly
- • Insurance pays contracted rate
- • You owe nothing more
- Total out-of-pocket: $30
Self-Pay with Superbill
- • You pay: $175 at session
- • Plan's UCR/allowed amount: $120
- • Plan pays 60% of UCR = $72
- • Your coinsurance: 40% of $120 = $48
- • Balance bill: $175 - $120 = $55
- Total out-of-pocket: $103
And this assumes you've already met your out-of-network deductible. If not, you receive no reimbursement until the deductible is met.
Watch Out for Misleading Claims
Some healthcare providers advertise that they "accept" your insurance, "work with all insurances," or are "insurance friendly." These phrases can be misleading:
- ⚠"We accept all insurances" — Often just means they'll give you a superbill to submit yourself. It does NOT mean they're in-network or that your costs will be lower.
- ⚠"We work with your insurance" — May mean they help you file claims, not that they have contracted rates.
- ⚠"Insurance friendly" — Vague language that doesn't indicate actual network participation.
Remember: No Surprises Act protections against surprise balance billing generally do NOT apply to routine outpatient therapy when you choose an out-of-network provider. If you're asked to pay the full session fee upfront and submit your own claims, you are a self-pay patient—entitled to a GFE, but not protected from balance billing.
Questions to Ask Any Healthcare Provider
Protect yourself by asking these questions before scheduling
Before scheduling with any healthcare provider, ask these specific questions. The answers will reveal exactly what your financial responsibility will be and whether you're entitled to a Good Faith Estimate.
"Are you in-network with my specific insurance plan?"
Why this matters: Being in-network with one plan from a carrier doesn't mean they're in-network with all plans from that carrier. Confirm your specific plan by name.
"Will you bill my insurance directly?"
Why this matters: This is the clearest indicator of true in-network status. In-network providers always bill your insurance directly—you never have to file claims yourself.
"What will I pay at the time of my appointment?"
Why this matters: The amount you pay upfront reveals your true status. In-network patients pay copays ($20-50 typically); self-pay patients pay full session fees ($150-250+).
"If you're out-of-network, what is your standard fee?"
Why this matters: If they're not in-network, you need to know the actual fee to compare against your plan's UCR/allowed amount and calculate your true out-of-pocket cost.
"Can you provide a Good Faith Estimate?"
Why this matters: If you're self-pay, this is your legal right. A provider's response tells you whether they understand and comply with federal requirements.
"Under what circumstances might my costs be higher than the estimate?"
Why this matters: GFEs are estimates, not guarantees. Understanding what could change helps you avoid surprises and know when you might have dispute rights.
The Definitive Test
Our Commitment to Transparency
How Complete Health Wellness Group handles insurance and billing
We believe patients deserve clarity about their healthcare costs and coverage status. Transparency isn't just good ethics—it's essential for building the trust that makes therapy effective.
- Clear network status: We maintain an up-to-date list of insurance plans we participate with and clearly distinguish between in-network and out-of-network arrangements. View our accepted plans →
- Direct billing for in-network patients: When we are in-network with your plan, we bill your insurance directly. You pay only your plan's cost-sharing (copay/coinsurance).
- Good Faith Estimates provided: We provide GFEs to all self-pay patients as required by law, delivered within the required timeframes before your appointment.
- Benefits verification assistance: We help you verify your coverage before your first appointment so there are no surprises. Learn how to verify benefits →
- Honest communication: We never use misleading language like "we accept all insurances" when we actually mean we provide superbills. If we're not in-network, we'll tell you directly.
Your Rights Under the No Surprises Act
Federal protections every patient should know
The No Surprises Act established important protections for healthcare consumers. Understanding these rights empowers you to advocate for yourself and ensure you receive the cost transparency you're entitled to.
Right to Request a GFE
You can request a Good Faith Estimate at any time—before scheduling, when scheduling, or even for hypothetical services you're considering. Providers cannot refuse this request for uninsured or self-pay patients.
Timely Delivery Required
Providers must furnish a GFE within specific timeframes: within 3 business days of scheduling (or 1 business day if scheduled less than 10 days out). For unscheduled requests, the GFE must be provided within 3 business days.
Dispute Resolution Rights ($400+ Threshold)
If your final bill exceeds your Good Faith Estimate by $400 or more, you can initiate the Patient-Provider Dispute Resolution (PPDR) process. Key details:
- • File within 120 calendar days of your original bill date
- • Small administrative fee applies (~$25)
- • Provider must suspend all collection activities during the dispute
- • Independent resolution entity reviews both sides
- • Decision typically within 30 business days
Right to Report Violations
If a provider refuses to provide a required GFE, provides one late, or otherwise violates the No Surprises Act requirements, you can report them. Providers face civil monetary penalties of up to $10,000+ per violation.
Balance Billing Protection
The No Surprises Act protects you from balance billing in specific situations: emergency care, care by out-of-network providers at in-network facilities, and air ambulance services. However, these protections generally do not apply to routine outpatient therapy when you voluntarily choose an out-of-network provider.
Where to Get Help
Federal Resources
- No Surprises Help Desk: 1-800-985-3059 (8am–8pm Eastern, 7 days/week)
- Online: CMS.gov/nosurprises
Maryland-Specific Resources
- Health Education and Advocacy Unit (HEAU): 410-528-1840 or 877-261-8807 (toll-free in MD)
- Maryland Insurance Administration: 800-492-6116 or insurance.maryland.gov
Key Takeaways
- 1.A Good Faith Estimate is your legal right as a self-pay or uninsured patient—providers must provide one within specific timeframes.
- 2."Accepting" insurance is not the same as being in-network. Ask specific questions to understand your true coverage status.
- 3.If you pay the full fee upfront and submit your own claims, you are self-pay—entitled to a GFE but not protected from balance billing.
- 4.You can dispute bills that exceed your GFE by $400 or more within 120 days through the federal PPDR process.
- 5.Providers who violate GFE requirements face penalties up to $10,000+ per violation—you have the right to report non-compliance.