You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
Make sure your health care provider gives you a Good Faith Estimate within the following timeframes:
- If the service is scheduled at least three business days before the appointment date, no later than one business day after the date of scheduling;
- If the service is scheduled at least 10 business days before the appointment date, no later than three business days after the date of scheduling; or
- If the uninsured or self-pay patient requests a good faith estimate (without scheduling the service), no later than three business days after the date of the request. A new good faith estimate must be provided, within the specified timeframes if the patient reschedules the requested item or service.
The No Surprises Act has a universal waiver form required
This is the public disclosure of the “Good Faith Estimate”
Note: A Good Faith Estimate is for your awareness only. It does NOT involve you needing to make any type of commitment.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059.
Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
If you have questions or concerns, please reach out.