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The good faith estimate a self-pay client is owed, with every element the rule lists.
45 CFR 149.610(c)(1) says what an estimate must contain: the client, the service and its date, the itemized list with codes and charges, your NPI and TIN and location, the separately-scheduled list, and four disclaimers. Type the facts; the page produces the document and tells you when it has to be delivered.
The facts →The facts
What the rule needs from you.
One estimate can cover a recurring service for up to 12 months if it states the frequency and number of sessions expected; a new one is due after that or when the scope changes. A diagnosis code goes on only if one applies; before a first appointment there often is none. Whether the client is self-pay at all is the question the superbill page covers.
The rule
Eleven elements and three clocks.
Patient name and date of birth; the primary service in clear language with its date; an itemized list for the period of care; applicable diagnosis codes, expected service codes and expected charges; the name, NPI and TIN of each provider and the state and location; the list of services needing separate scheduling, with its disclaimer; and disclaimers that other recommended services may not be reflected, that it is only an estimate, that the client may start dispute resolution if billed substantially more and where to find out how, and that it is not a contract. 45 CFR 149.610(c)(1)(i)–(xi).
Scheduled at least 3 business days out: within 1 business day of scheduling. At least 10 out: within 3. On request: within 3 business days of the request. A new estimate when the scope changes, no later than 1 business day before the service.
The availability of an estimate must be written clearly, displayed prominently in the office and on the website, said aloud at scheduling, and offered in the client’s language; any discussion of cost is treated as a request.
“Substantially in excess” means at least $400 more than the estimate’s total for that provider; the client has 120 calendar days from the bill to start the process.
Then what
Around the estimate.
The rule in full
Superbills and the good faith estimate
Who is self-pay, what the notice must say, and the superbill the client files.
A private worksheet
Good faith estimate preparation
The checklist form of the same rule, kept in your browser.
The fee, disclosed first
The fee disclosure statement generator
Your fee and policies with CMS’s estimate notice, the document that says an estimate exists.
Are you a covered entity at all?
The HIPAA self-check
Self-pay only is not the same as outside HIPAA; the estimate rule applies either way.
Where every figure came from
Sources.
The rule
CMS materials
Nothing typed leaves the browser; the printed document is built in a new window from the fields and is not kept anywhere by this site. Service descriptions are the CPT code titles in plain words; the codes themselves are the AMA’s.
