CMS Provides Guidance on Good Faith Estimates for No Surprises Act

CMS has released 11 documents to help providers comply with the No Surprises Act’s requirement that providers give patients a “good faith estimate” of expected charges.

The No Surprises Act was passed as part of the Consolidated Appropriations Act, 2021. The Act will prohibit surprise medical billing in most healthcare situations starting Jan. 1, 2022. As part of No Surprises Act compliance, providers and facilities will need to be able to inform patients, both orally and in writing, of a cost estimate if they are not enrolled in a plan or are covered by a federal healthcare program, or who are not seeking to file a claim with their insurance for care. This “good faith estimate,” as the Act calls it, must be given upon request or at the time of scheduling.

Included in the documents released by CMS is a template for providers and healthcare facilities to use to deliver good faith estimates under the No Surprises Act. CMS says one of the documents (CMS-10791 – 11. 2. Good Faith Estimate Template) that providers can “fill in the blanks” with their own information and HHS will consider the use of the template to be in compliance with the No Surprises Act.

Data elements on the template include patient demographic information, diagnosis, and expected provider and facility charges. Providers can explore all the data elements required for a good faith estimate in the document titled “CMS-10791 – 11. HHS – Appendix Good Faith Estimate Data Elements.

Providers can use the template when the No Surprises Act will be effective, CMS states.

The federal agency also provided a template that gives patients more information about their good faith estimates. The document (CMS-10791 – 1. Right to Receive a Good Faith Estimate of Expected Charges Notice) can be used starting Jan. 1, 2022, to inform patients of what a good faith estimate is and provider requirements for providing one. For example, providers must give a good faith estimate in writing at least one business day before the medical service or item is furnished. Additionally, patients can dispute their final medical bill if the charges are at least $400 more than the good faith estimate provided.

If patients dispute their medical bills, CMS has also provided templates for documents it and providers will send to patients.

The No Surprises Act will establish a patient-provider dispute resolution process in which a “selected dispute resolution” (SDR) entity is charged with resolving disputes over medical bills involving uninsured or self-pay patients. The process is different from the independent dispute resolution process, which will settle discrepancies between providers and payers over disputed medical bills.

Among the templates is a standard notice for ineligible claims (CMS-10791 – 3. SDRE Declining eligibility or Need More Information Notice), a dispute initiation form (CMS-10791 – 4. PPDR – Dispute Resolution Form), an SDR determination notice (CMS-10791 - 8. PPDR - SDRE Determination Notice), an SDR selection notice (CMS-10791 - 9. PPDR - SDRE Selection Notice), and a payment settlement form (CMS-10791 - 10. PPDR - Payment Settlement Form).

Other documents supporting the patient-provider despute resolution process include three appendices (CMS-10791 - 5. HHS - Appendix SDR Entity Certification Data Elements_508c, CMS-10791 - 6. HHS - Appendix Vendor Management (VM) Data Elements, and CMS-10791 - 7. HHS - Appendix PPDR Data Elements for Patients and Providers) that detail data elements for the process.