Your Good Faith Estimate, and the $400 Dispute Rule

If you are paying cash, a federal law already put a number in your hands before anyone treated you. Since January 1, 2022, the No Surprises Act requires providers to give patients who aren’t using insurance a written Good Faith Estimate of what care will cost. Most people never get one, because most people never ask. The estimate matters for a reason beyond planning: if a provider ends up billing you at least $400 more than that provider’s own written estimate, you can open a federal dispute, an independent reviewer decides what you actually owe, and the whole thing costs $25. That is the shortest path there is from a price you were quoted to a price you can hold someone to.

The rule applies to you if you don’t have health insurance, or if you have it and are choosing not to use it for this care — which is exactly the position most people reading MarketCare are in. The regulation defines an uninsured or self-pay individual to include someone who has coverage but does not seek to have the claim submitted to it. So tell the provider up front that you’re self-pay. From there, CMS states that in most cases providers and facilities must give you an estimate when you schedule care at least 3 business days in advance, or if you ask for one. Business days means Monday through Friday. You do not need to use the words “good faith” to trigger it; asking for a written estimate of expected charges is enough — and an authorized representative can ask on your behalf.

The estimate should cover expected charges for the items and services involved, including facility fees and hospital fees — the line items that make a hospital bill unrecognizable next to the number you were quoted on the phone. Emergency care is the carve-out: you won’t get an estimate during an emergency.

How fast they have to produce it

The regulation puts the deadline on the provider, not on you, and it runs on three separate clocks. If you schedule an item or service at least 3 business days ahead, the estimate is due no later than 1 business day after scheduling. If you schedule at least 10 business days ahead, it is due no later than 3 business days after scheduling. And if you simply request an estimate without scheduling anything, it is due no later than 3 business days after your request. If a week goes by with nothing, they are late.

How to tell you got a real one

A compliant estimate is a specific document, not a number scribbled on a card. Under the regulation it must carry your name and date of birth, a clear-language description of the primary item or service, an itemized list of items and services grouped by provider or facility, the applicable diagnosis codes and service codes with expected charges for each, and each provider’s name, National Provider Identifier, taxpayer ID and location. It must also list items that will need their own separate estimates later, and carry disclaimers stating that it is not a bill, that actual charges may differ, and that you have a right to initiate the dispute process if the charges come in substantially above it. If what you received has no codes and no NPI, ask for the real thing.

The threshold is $400 — but it is measured per provider, not across your whole bill. CMS’s wording is that you can dispute a bill if one of your providers or facilities charged at least $400 more than their estimate. A day that produces four bills totalling $3,000 over your combined estimates is not automatically disputable; a single anesthesiologist who estimated $600 and billed $1,100 is. This is the detail that decides whether a dispute gets accepted, and it is the reason section I insists on collecting an estimate from every provider separately.

1. 1
   Check the six eligibility facts

   You didn’t have or didn’t use insurance; you told the provider that in advance; the care happened on or after January 1, 2022; you have a written good faith estimate; your initial bill is dated within the last 120 calendar days; and one provider charged at least $400 over their own estimate.

2. 2
   Gather three documents

   The good faith estimate, the bill, and the provider’s contact information. CMS asks for digital or paper copies — and tells you not to mail original documents.

3. 3
   File within 120 days of the initial bill

   The clock runs from the date of your initial bill, which is roughly four months. CMS’s own guidance on this is short: it’s important not to delay. You can file through the online form, which asks for your email and a one-time PIN, or by mail or fax using CMS’s printable form.

4. 4
   Pay the $25 fee

   The dispute doesn’t start until the $25 non-refundable administrative fee is paid. Online you can pay by credit card, PayPal, or Venmo; by mail, money order or cashier’s check. Cash and personal checks aren’t accepted.

5. 5
   An independent reviewer decides

   The process brings in an independent third party — a dispute resolution entity — to review the bill and determine an appropriate payment amount.

The economics are unusually friendly for a consumer process. The fee is $25, and if the dispute is decided in your favor, that $25 comes off what you owe your provider. If you and the provider settle between yourselves before the reviewer rules, the provider is required to reduce your bill by at least $12.50 — half the fee — and to notify the reviewer that you’ve settled.

If a dispute is decided in your favor and the provider keeps billing you anyway, or sends it to collections, CMS’s instruction is to submit a complaint to the No Surprises Help Desk. If a debt collector contacts you about an unexpected out-of-network medical bill, or a surprise charge shows up as a negative item on your credit report, the Consumer Financial Protection Bureau takes those complaints at 1-855-411-2372.

HHS assigns a certified Selected Dispute Resolution entity to run the process, and either side can flag a conflict of interest, in which case a new entity is assigned. Once the entity confirms the item or service is eligible, the provider has no later than 10 business days to submit its own documentation — its copy of the estimate, its copy of the bill, and any justification for the difference. The entity then has no later than 30 business days from receiving that documentation to issue a payment determination. If your initiation notice is incomplete, you get 21 calendar days to fix it, extendable to 35 in accessibility-related circumstances.

The determination is binding on both parties absent fraud or misrepresentation. You and the provider remain free to settle for a different amount at any point before it is issued — and if you do, the provider still has to knock at least $12.50 off your bill and tell the reviewer.

Two boundaries are worth knowing before you spend an afternoon on this. The patient-provider dispute process described here is for people who are uninsured or not using insurance. If you used your insurance, this isn’t your lane — your route runs through the appeals process described in your plan’s documents and denial notices. And a bill arriving because you haven’t met your deductible is not a No Surprises Act violation; CMS says so explicitly. That is a coverage-design outcome, not a billing violation.

A good faith estimate tells you what one provider intends to charge you. It doesn’t tell you whether that number is any good. That’s the comparison MarketCare exists to make: the same procedure, priced at every Austin provider we’ve been able to verify, so an estimate can be read against a market instead of against nothing. Two different jobs, and they work best together — shop the price first, then get the estimate in writing from whoever you pick.