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

APPENDIX 11

OMB Control Number: 0938-NEW
Expiration Date: XX/XXXX

Good Faith Estimates
Data Elements
Under Section 2799B-7 of the Public Health Service Act and its implementing regulations,
the U.S. Department of Health & Human Services (HHS) is required to establish a patientprovider dispute resolution process where a SelectedDispute Resolution (SDR) entity can
resolve a payment dispute between individuals who are not enrolled in a group health plan, or
group or individual health insurance coverage, or a Federal health care program, or a Federal
Employees Health Benefits (FEHB) program health benefits plan (uninsured individuals), or
who are not seeking to file a claimwith their group health plan, health insurance coverage, or
FEHB health benefits plan (self-pay individuals), and health care provider, facility, or
provider of air ambulance services by determining the amount such individual must pay to
their health care provider, facility, or provider of air ambulance services. Under federal
criteria, SDR entities will review initiation notices to determine that an uninsured (or selfpay) individual is eligible to dispute a bill.
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(c)(1)(iii)(B), the good faith estimate information submitted by coproviders or co-facilities, as specified in 45 CFR 149.610(b)(2) and (c)(2) 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.
DATA ELEMENT

DESCRIPTION

Good Faith Estimate submitted by Convening Provider or Convening Facility
Name and date of birth of the uninsured First name, last name, and date of birth for the uninsured
(or self-pay) individual
(or self-pay) individual receiving items or services.
Account Number (last four digits)
(optional)

The number that is assigned to the patient in order to help
the provider identify the patient, date(s) of service, and
items and services.

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DATA ELEMENT

DESCRIPTION

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.

Itemized list of items and services
reasonably expected to be furnished for
the primary item or service, and items or
services reasonably expected to be
furnished in conjunction with the
primary item or service 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), Diagnosis-Related
Group (DRG), or National Drug Code (NDC) codes.

Diagnosis codes (if required for the
calculation of the GFE)

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.

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.
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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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.

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
from any provider or facility are $400 more than the
expected charges from that provider or facility 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 self-pay)
individual to obtain the items and services from any of
the providers or facilities identified on the good faith
estimate.
Good Faith Estimate submitted by Co-Providers or Co-Facilities to Convening Providers or
Convening Facilities
Name and date of birth of the uninsured First name, last name, and date of birth for the uninsured
(or self-pay) individual
(or self-pay) individual receiving items or services.
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DATA ELEMENT

DESCRIPTION

Itemized list of items and services
Itemized list of items or services that are reasonably
expected to be furnished by co-provider expected to be furnished in conjunction with the primary
or co-facility
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 (if required for the
calculation of the GFE)

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 co-facilities

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 self-pay)
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 valid OMB control number for this information collection is
1210-0169. 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 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.

PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and
any supporting documentation under section 2799B-7 of the Public Health Service Act, as added
by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations
Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to
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initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to
determine whether any conflict of interest exists with the independent dispute resolution entity
selected to decide your dispute. The information may also be used to: (1) support a decision on
your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate
selected IDR entity’s compliance with program rules. Providing the requested information is
voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could
cause your dispute to be decided in favor of the provider or facility.

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