Good Faith Estimate

Under the law, health care providers need to give patients who don’t have insurance or who are not using their health insurance coverage an estimate of the bill for medical and/or dental items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like appointment cost, medical tests, prescription drugs, and equipment fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least one (1) business day before your medical service or item, if the service is scheduled at least three (3) days in advance. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate and the bill.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (800) 985-3059.

Disclaimer: This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

Right to Dispute: You may contact us to let us know that the billed charges are higher than the GFE. You can ask to update the bill to match the GFE, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolutions process with the US Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the 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 after reviewing it is determined in your favor you would pay the price on the GFE, if resolution is with us then you would pay the higher amount.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call (800) 985-3059.