Notice of Right to Good Faith Estimate – Wholly Physician-Owned Private Practices

OMB Control Number: 0938-XXXX
Expiration Date: xx/xx/xxxx
APPENDIX 11
Good Faith Estimates
Data Elements
The Departments of the Treasury, Labor, and Health and Human Services (collectively, the
Departments) have issued interim final rules titled the “Requirements Related to Surprise Billing;
Part II” (XX FR XXXXX, date of publication). In the interim final rule, HHS requires health
care providers and health care facilities to provide a good faith estimate of the total expected
charges to individuals who are not enrolled in a plan or coverage or a Federal health care
program (uninsured individuals), or individuals who are enrolled but not seeking to file a claim
with their plan or coverage (self-pay individuals) of the expected charges they may be billed for
receiving certain health care items and services upon scheduling items and services, or upon the
request of such individual. The authority for this requirement is PHS Act section 2799B-6 and
the interim final rule at 45 CFR 149.610. Section 45 CFR 149.610(c), establishes requirements
for the content that must be included in a good faith estimate that is issued to an uninsured (or
self-pay) individual. Per 45 CFR 149.610(c)(1), all of the required elements must be included in
the good faith estimate that the convening provider or convening facility issues to the uninsured
(or self-pay) individual. As specified in 45 CFR 149.610(b)(1) and (2), the good faith estimate
information submitted by co-providers or co-facilities must also be included as part of the good
faith estimate issued to the uninsured (or self-pay) individual.
The table below identifies data elements that health care providers and facilities, are required to
include in the good faith estimate beginning on January 1, 2022. From January 1, 2022 through
December 31, 2022, HHS will exercise its enforcement discretion in situations where the good
faith estimate does not include expected charges for items and services from a co-provider or cofacility. These data elements must be provided by a co-provider or co-facility beginning January
1, 2023.
Good Faith Estimate submitted by Convening Provider or Convening Facility
DATA ELEMENT

DESCRIPTION

Patient name and date of birth

First name, last name, and date of birth for the
uninsured (or self-pay) individual receiving items or
services.

Description of the primary item or
service in clear and understandable
language (and if applicable, the date
the primary item or service is
scheduled)

A description of the item or service to be furnished by
the convening provider or facility (as defined for
purposes of 45 CFR 149.610) that is the initial reason
for the visit.

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OMB Control Number: 0938-XXXX
Expiration Date: xx/xx/xxxx
DATA ELEMENT

DESCRIPTION

Items and services reasonably
expected to be furnished for the
period of care

An itemized list of the items and services, grouped by
each provider or facility, reasonably expected to be
furnished to the uninsured (or self-pay) individual,
reasonably expected to be provided for the primary
item or service, and items and services expected to be
furnished in conjunction with and in support of the
primary item or service, for that period of care
including: (1) those items and services expected to be
furnished by the convening provider or facility, and
(2) those items and services expected to be furnished
by co-providers or co-facilities, for the period of care.

Service codes

Description of an item or service using the Current
Procedural Terminology (CPT), Healthcare Common
Procedure Coding System (HCPCS), DiagnosisRelated Group (DRG), or National Drug Code (NDC)
codes.

Diagnosis codes

The code that describes an individual’s disease,
disorder, injury, and other related health conditions
using the International Classification of Diseases
(ICD) code set.

Expected charges

Expected charges associated with each listed item or
service.

Names of providers and facilities

First name, last name, and title of providers. Facilities
legal name as written on their business license.

Tax ID Number

Provider or facility’s taxpayer identification number
(TIN), employer identification number (EIN), or
federal tax identification number (FTIN) issued by the
Internal Revenue Service.

National Provider Identifier

Provider or facility’s National Provider Identifier.

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OMB Control Number: 0938-XXXX
Expiration Date: xx/xx/xxxx
DATA ELEMENT

DESCRIPTION

List of items and services requiring
separate scheduling

A list of items and services that the convening
provider or convening facility anticipates will require
separate scheduling and are expected to occur either
prior to or following the expected period of care for
the primary item or service. The good faith estimate
must include a disclaimer directly above this list that
states that separate good faith estimates will be issued
to an uninsured (or self-pay) individual upon
scheduling of the listed items and services; for items
and services included in this list, information such as
diagnosis codes, service codes, expected charges and
provider or facility identifiers need not be included as
that information will be provided in separate good
faith estimates upon scheduling of such items and
services.

State(s) and office or facility
location(s)

Physical address, including street name and number,
city, state, and zip code for all providers and facilities
involved in the expected period of care.

Disclaimer stating that good faith
estimate is an estimate and subject to
change

Disclaimer informing the uninsured (or self-pay)
individual that the information provided in the good
faith estimate are estimates and not the final overall
total charges.

Disclaimer stating that there may be
additional items or services not
contained in good faith estimate

Disclaimer informing the uninsured (or self-pay)
individual that additional items and/or services that
are not in the good faith estimate may be
recommended by the convening provider as part of
the course of care, that must be scheduled separately
and are not reflected in the good faith estimate (such
as rehabilitation therapies or other post treatment
items or services) and information regarding how an
uninsured (or self-pay) individual can obtain a good
faith estimate for such items or services.

Disclaimer of their right to initiate
the patient-provider dispute
resolution process

Disclaimer providing the uninsured (or self-pay)
individual of their right to initiate the patient-provider
dispute resolution process if the actual billed charges
are $400 more than the expected charges included in
the good faith estimate.

Disclaimer that the good faith
estimate is not a contract

Disclaimer stating that the good faith estimate is not a
contract and does not require the uninsured (or selfpay) individual to obtain the items and services from
any of the providers or facilities identified on the good
faith estimate.
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OMB Control Number: 0938-XXXX
Expiration Date: xx/xx/xxxx

Good Faith Estimate submitted by Co-Providers or Co-Facilities to Convening Providers
or Convening Facilities
DATA ELEMENT

DESCRIPTION

Patient name and date of birth

First name, last name, and date of birth for the
uninsured (or self-pay) individual receiving items or
services.

Items and services expected to be
furnished by co-provider or cofacility

Items or services that are reasonably expected to be
furnished in support of and in conjunction with the
primary item or service for the period of care.

Service codes

Description of an item or service using the CPT code,
HCPCS, DRG, or NDC codes.

Diagnosis codes

The code that describes an individual’s disease,
disorder, injury, and other related health conditions
using the ICD code set.

Expected charges

Expected charges associated with each listed item or
service.

Names of co-providers and cofacilities

First name, last name, and title of co-providers. Cofacilities legal name as written on their business
license.

Tax ID Number

Provider or facility’s TIN, EIN, or FTIN issued by the
Internal Revenue Service.

National Provider Identifier

Provider or facility’s National Provider Identifier.

State(s) and office or facility
location(s)

Physical address, including street name and number,
city, state, and zip code.

Disclaimer that the good faith
estimate is not a contract

Disclaimer stating that the good faith estimate is not a
contract and does not require the uninsured (or selfpay) individual to obtain the items and services from
any of the providers or facilities identified on the
good faith estimate.

Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid Office of Management and Budget
(OMB) control number. The Departments are seeking OMB approval for the model as part
of the approval for a new OMB control number 0938-XXXX. The time required to
complete this information collection is estimated to average of 2 hours per respondent,
including the time to review instructions, search existing data resources, gather the data
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OMB Control Number: 0938-XXXX
Expiration Date: xx/xx/xxxx
needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.

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