Patient Cost Estimates: Good Faith Estimates and Out-of-Network Benefits

Updated November 5, 2026, based on HHS, CMS, CAQH CORE and the Federal Register as of that date.

A good faith estimate is required when a patient is uninsured or chooses not to bill their insurance. Federal rules set what goes on it and when it's due: within 1 business day of scheduling for visits booked 3 to 9 business days out, and within 3 business days for visits booked 10 or more days out or when the patient asks. For insured patients billing their plan, the federal requirement isn't enforced yet. Their estimate comes from the plan's benefits: the deductible, copay and coinsurance on the eligibility response, applied to the allowed amount.

The allowed amount is why out-of-network estimates are hard. In network, you can work from your contracted rate and the 271 response. Out of network, the 271 can give you the patient's coinsurance percentage, but the dollar amount it applies to sits with the payer.

Who gets a good faith estimate

Under 45 CFR 149.610, providers and facilities owe a good faith estimate to uninsured or self-pay patients. That means patients with no coverage from a group health plan, individual or group insurance, a Federal health care program or a Federal Employees Health Benefits plan. It also means patients who have commercial or FEHB coverage but don't want a claim submitted for this service.

The convening provider, the one who schedules the primary service, has to ask whether the patient has coverage and wants a claim filed. It must tell every uninsured or self-pay patient that estimates are available, on its website, in the office and out loud when scheduling or when cost comes up. Under the rule, any discussion or inquiry about potential costs counts as a request for an estimate.

CMS's first good faith estimate FAQ says providers generally don't owe these estimates to patients insured under Medicare, Medicaid or other federal health care programs. For patients with commercial coverage who want the claim filed, the same FAQ says HHS will defer enforcement until it writes rules for estimates sent to plans. The regulatory agenda entry for that rule, tied to the Advanced Explanation of Benefits, lists it at the proposed rule stage. State law may add its own estimate rules, so check yours.

Good faith estimate deadlines

Deadlines depend on how far ahead the service is scheduled. CMS's patient guide to good faith estimates lays them out like this:

• Scheduled 0 to 2 business days ahead: not required
• Scheduled 3 to 9 business days ahead: within 1 business day of scheduling
• Scheduled 10 or more business days ahead: within 3 business days of scheduling
• Patient asks without scheduling: within 3 business days of the request

If the services, charges, providers or facilities change after scheduling, the patient needs a new estimate at least 1 business day before the service. A patient who got an estimate on request gets a new one when they schedule. For recurring care, one estimate can cover up to 12 months if it states the frequency and total number of visits.

The rule also calls for charges from co-providers and co-facilities, such as an anesthesiologist or lab working alongside the scheduling provider. HHS isn't enforcing that part. CMS's December 2022 FAQ extended enforcement discretion "pending future rulemaking" for estimates that leave out co-provider charges, and the CMS patient guide tells patients that estimates "only list expected charges for a single provider or facility." The convening provider still estimates its own charges.

What goes on the estimate

Section 149.610(c) lists the contents:

1. Patient name and date of birth.
2. A plain-language description of the primary service and its scheduled date.
3. An itemized list of expected items and services, grouped by provider or facility.
4. Diagnosis codes, expected service codes (CPT, HCPCS, DRG or NDC) and expected charges for each item.
5. Name, NPI and TIN of each provider or facility, and where services will happen.
6. Services that will be scheduled separately, with instructions for getting estimates for them.
7. Disclaimers that the estimate isn't a contract, that actual charges may differ, that other recommended services may need separate scheduling, and that the patient can dispute a bill well above the estimate.

For an uninsured patient, the expected charge is your cash or self-pay rate, including discounts. The estimate must be written, on paper or electronically as the patient prefers, in a form they can save and print. You can walk a patient through it by phone, but you still send the written copy. It becomes part of the medical record, and patients can request copies from the past 6 years.

The $400 dispute threshold

Under 45 CFR 149.620, an uninsured or self-pay patient can start patient-provider dispute resolution when a provider's or facility's total billed charges are at least $400 more than its expected charges on the estimate. The patient has 120 calendar days from the first bill to file. The threshold applies to each provider or facility separately.

Under 149.610(f), an honest error made with reasonable diligence isn't a compliance failure if you correct it as soon as practicable. If the service happens before the correction, the bill can still go to dispute, so re-issue the estimate whenever the plan of care changes.

Estimating for insured patients: the 271 and the plan's own tool

For a patient billing their plan, start with an eligibility and benefits check, the X12 270 inquiry and 271 response. HIPAA's eligibility operating rules at 45 CFR 162.1203 adopt CAQH CORE's Phase I and II data content rules, in their 2011 versions. CAQH CORE's current eligibility data content rule, published in June 2025, requires the 271 to carry, for its required service types:

• Base and remaining deductible, individual and family, in dollars.
• Copay and coinsurance.
• Separate in-network and out-of-network amounts when they differ, flagged in EB12 with N or Y.
• A non-covered flag for out-of-network when a benefit is covered in network only.

The remaining deductible is as of the date of the 271, so a check run at scheduling can be stale by the visit. Plans may skip financial details for service types the rule marks as discretionary, which leaves you checking the portal or calling. Our guide to insurance eligibility verification automation covers running these checks at volume.

The 271 gives you the patient's share, not the price it applies to. In network, that price is your contracted rate. Rates can vary across one payer's plans, so match the rate to the patient's plan, not just the payer.

Patients can also check the plan's numbers. Under the Transparency in Coverage rule at 45 CFR 147.211, non-grandfathered group health plans and individual market insurers must give members, on request, an estimate of their cost sharing for a covered service. It includes accumulated amounts toward the deductible and out-of-pocket limit, the in-network rate and, for out-of-network providers, the allowed amount. Members get it through an online self-service tool, or on paper mailed within 2 business days. A final rule published in October 2026 adds phone requests through the number on the member ID card, for plan years beginning on or after January 1, 2027. When a patient asks you to work out their deductible and out-of-pocket balance, give your estimate and point them to that tool too.

Why out-of-network estimates are hard

An out-of-network bill depends on three numbers: your charge, the plan's allowed amount, and the patient's cost sharing on that allowed amount. The 271 can give you the third. The CORE rules don't require the second.

Under 147.211, the member's tool must show the out-of-network allowed amount, or the percentage of billed charges if the plan pays that way. That disclosure goes to the member, not to you. Unless the patient shares it, you are asking the payer or working from what it has paid you on similar claims.

The site of care also matters. Under the No Surprises Act rules at 45 CFR 149.420, an out-of-network provider working at an in-network facility can't balance bill the patient above in-network cost sharing unless the patient signs a notice and consent. For non-emergency care, 45 CFR 149.30 defines those facilities as hospitals, hospital outpatient departments, critical access hospitals and ambulatory surgical centers. The same out-of-network surgeon can face different rules at an in-network surgery center than at an office. The plan's tool also has to account for factors such as location of service and facility name where they affect cost sharing.

Notice and consent never applies to ancillary services under 149.420(b): emergency medicine, anesthesiology, pathology, radiology, neonatology, assistant surgeons, hospitalists, intensivists and diagnostic services, including lab work. Where it does apply, the notice must include a good faith estimate of the out-of-network provider's charges. It must reach the patient at least 72 hours before the service, or on the day of scheduling for appointments booked within 72 hours, and no later than 3 hours before same-day care.

A workable estimate process

1. At scheduling, ask whether the patient has coverage and wants the claim filed. An uninsured patient, or a commercially insured patient who doesn't want a claim filed, starts the good faith estimate clock.
2. Confirm network status for the patient's specific plan, the rendering provider and the site of care, not just the group contract.
3. Run the 271 for the right service type. Record in-network and out-of-network amounts separately, with the date of the remaining deductible.
4. Price it: your contracted rate in network; for out-of-network, the payer's allowed amount or the figure from the patient's plan tool.
5. Write down the deductible, copay and coinsurance math, and what could change it.
6. Re-check before the visit, and re-issue any good faith estimate that changes at least 1 business day before the service.

Tell patients about their deductible at scheduling rather than at check-in, so they have time to plan for it.

Frequently asked questions

Do Medicare and Medicaid patients get a good faith estimate?

In most cases, no. CMS's FAQ says the No Surprises Act generally doesn't require them for patients insured under Medicare, Medicaid or other federal health care programs. State rules and payer contracts may differ.

Is a good faith estimate required for insured patients?

The statute calls for one, sent to the plan, but HHS has deferred enforcement until it issues rules. That rulemaking is still at the proposed rule stage.

Why doesn't the eligibility response show what the payer allows out of network?

The CORE rules require patient cost sharing, not plan pricing. The out-of-network allowed amount appears in the member's Transparency in Coverage tool, or you get it from the payer directly.

Checking benefits before every scheduled visit?

Champ automates portal work like eligibility and benefits checks, so the deductible, copay and network details are ready before patients call. We set it up and run it, so your staff sees only the finished results. If cost estimates are slowing down your front desk, learn more here.

This post is general information, not legal, compliance or billing advice. Rules vary by state and payer and change often, so confirm with your compliance team, your state regulator or the payer before acting. Champ is not affiliated with or endorsed by HHS, CMS or CAQH CORE.