“Good Faith Estimate for Services” Under the No Surprises Act

The Consolidated Appropriations Act of 2021 established new requirements for providers to protect consumers from surprise medical bills. These requirements are collectively referred to as “No Surprises” rules. The goal is of protect clients from unexpected bills for healthcare services, such as charges for out-of-network emergency care. Many of its provisions do not apply directly mental health providers. However, beginning January 1, 2022, mental health providers will be required by the federal law to give uninsured and self-pay clients a good faith estimate of costs for services that they offer, when scheduling care or when the client requests an estimate.”

Here are some key features of the “good faith estimate” disclosure requirements:

The disclosure requirements apply to all healthcare providers, including mental health providers who treat self-pay and/or uninsured clients.

  • Providers must ask about insurance coverage, including whether the client intends to submit claims to insurance.
  • Providers must inform all self-pay and uninsured clients that a good faith estimate of charges is available.
  • A good faith estimate of expected charges must be given to the client within specified time frames (e.g., for services scheduled at least 3 days prior to the appointment date, no later than 1 business day after the date of scheduling).
  • The estimate is not binding. However, clients may challenge a bill if the charges substantially exceed the estimated amount.
  • If there are changes to the information in the good faith estimate, a new estimate should be provided.
  • The estimate can include anticipated charges for recurring services that are expected to be provided within the next 12 months (e.g., 10-20 therapy sessions). If treatment continues beyond 12 months, the provider must give the client a new estimate.
  • These disclosure requirements apply to existing as well as new clients.

If you provide services to self-pay and/or uninsured clients, the following form can be used.

The form is provided as a courtesy by Starship Care, LLC. It is expected that providers will modify the form to fit their individual practice. Have the client sign it, provide them a copy and keep a copy in their chart, paper or electronic.  It is recommended this form be provided at the outset of treatment and updated as needed.  To use this form, fill in the blanks with the appropriate information.  If you are providing the same service repeatedly, you do not need to fill in every date.  Simply write in the frequency e.g. weekly, ongoing, as needed, etc. Per the new law, both a diagnosis and CPT code (service code) should be included. Also, your NPI and TIN are noted requirements, though this may only be applicable if you bill insurance companies for any of your services.

These instructions are intended only to be a general informal summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or formal policy guidance upon which it is based. Users should refer to the applicable statutes, regulations, billers, and other interpretive materials for complete and current information or consult a qualified attorney.

Some links for sample forms and more background.

Standard Notice and Consent Documents Under the No Surprises Act (cms.gov)

Editable Sample No Surprises Form

No Surprises Act | CMS

Overview of rules & fact sheets | CMS

Text – H.R.3630 – 116th Congress (2019-2020): No Surprises Act | Congress.gov | Library of Congress


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