Services and Insurances 

If a Good Faith Estimate is required to be furnished, the counselor must notify the client both orally and in writing that a Good Faith Estimate will be provided upon scheduling or request. This requires the provider to:​

• Inform the client in a clear and concise written document of the right to receive a Good Faith Estimate (counselors may use the Standard Notice form);

• Must orally provide notice of the Good Faith Estimate when service is scheduled or when the patient asks about cost;

• Make the notice available in accessible formats and languages; and

• Prominently display the notice on the convening provider’s or facility’s website, in the office, and on-site where scheduling or questions about the cost of items and/or services typically occur.

The Good Faith Estimate must be provided within:​

• If a service is scheduled at least three (3) days in advance, the Good Faith Estimate must be provided not later than one (1) business day after the date of scheduling;

• If a service is scheduled at least ten (10) days in advance, the Good Faith Estimate must be provided not later than three (3) business days after the date of scheduling;

• If the Good Faith Estimate is otherwise requested by an uninsured or self-pay individual, the Good Faith Estimate must be provided not later than three (3) business days after the request.

The Good Faith Estimate issued by a convening provider and/or facility must include the following:​

• Client’s name and date of birth;

• A clear description of the primary item or service and, if applicable, the date the primary item or service is scheduled;

• Itemized list of items or services grouped by each provider or facility, reasonably expected to be provided for the primary item or service, and items or services reasonably expected to be furnished in conjunction with the primary item or service for that period of care;

• Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service;

• Name, NPI, and TIN of each provider or facility represented in the Good Faith Estimate, and the state(s) and office or facility location(s) where the items or services are expected to be furnished by such provider or facility;

• List of items or services that the convening provider or convening facility anticipates will require separate scheduling and that are expected to occur before or following the expected period of care for the primary item or service;

• Disclaimers that there may be additional items or services the convening provider/facility recommends that must be scheduled or requested separately;

• Must state that the information provided in the Good Faith Estimate is only an estimate of items or services reasonably expected to be furnished at the time the Good Faith Estimate is and that actual charges may differ;

• Must state that the client has the right to initiate the client-provider dispute resolution process if the actual billed charges are substantially more than the expected charges included in the Good Faith Estimate; and

• Must state that the Good Faith estimate is not a contract and does not require the uninsured or self-pay individual to obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate.