Good Faith Estimate for therapists: the four required disclosures

Who needs a Good Faith Estimate

The rule covers uninsured clients and self-pay clients — people who have insurance but are not going to bill it for the service. The subtle part: if a client’s plan has no out-of-network coverage at all, that client counts as self-pay for an out-of-network therapist even though they are insured.

That makes the obligation much broader for private-pay practices than it first appears. A client with a high deductible who still has OON benefits is not automatically self-pay, but a client whose plan simply does not cover out-of-network care is.

When it has to be delivered

Timing is measured in business days from the request or the booking, not from the first session:

• Service scheduled at least 3 business days out: GFE within 1 business day of scheduling.
• Service scheduled at least 10 business days out: GFE within 3 business days of scheduling.
• A request with no appointment yet: within 3 business days of the request.
• The estimate changes: an updated GFE at least 1 business day before the service.
• Appointments inside 3 business days: the advance GFE is not required (same for emergencies).

The four required disclosures

45 CFR 149.610(c) lists what the document must contain. Alongside the client name and date of birth, a plain-language description of the service and its date, the itemised expected charges with diagnosis and service codes, and each provider’s name, NPI, TIN and location, there are four disclaimers that have to appear:

• Additional recommended services may be needed and are not included in this estimate; those would come with their own GFE.
• This estimate is only an estimate — the actual services and charges may differ.
• The client has the right to start a patient–provider dispute resolution (PPDR) process if the actual bill is substantially higher, with instructions on how to start it and a statement that doing so will not affect the quality of care.
• The GFE is not a contract and does not require the client to receive care from this provider.

The $400 trigger and the 120-day window

If the final bill exceeds the estimate by at least $400, the client may start PPDR. They have 120 days from receiving the bill to notify HHS and pay the $25 administrative fee. The provider then has 10 days to send the GFE, the bill, and supporting documentation, and a selected dispute resolution entity decides within 30 days. Collection activity and late fees are suspended while the dispute is open.

One GFE can cover recurring services for up to 12 months, as long as it states the scope, frequency and expected number of visits. CAMFT’s guidance suggests using ranges — for example, twelve to thirty sessions with an estimated total range — rather than a single number.

Retention, placeholders and the "not a contract" trap

A GFE is part of the client record and has to be reproducible for 6 years. If the client has not been diagnosed yet, the counselling association guidance is to use a placeholder such as Z03.89 (no diagnosis) or R69 (illness, unspecified) and update it after the intake.

Because the GFE must state that it is not a contract, do not paste it into your informed-consent or treatment agreement — keep it a separate document so the two messages do not collide. And there is no waiver: the regulations give clients no way to give up the right to a GFE.

GFE and superbill are opposite directions

A superbill is retrospective: it documents services already delivered and paid for, it must carry diagnosis codes, and the client sends it to the insurer. A GFE is prospective: it estimates costs before care, it goes to the client, and it never goes to a payer.

Both documents draw on the same provider, client and fee data — which is why it is convenient to produce them from one place. But they cannot share a template: the GFE needs the four disclosures and the PPDR instructions, and it must not look like a claim form. The tool keeps them separate, and the GFE template is a later milestone rather than a re-skinned superbill.

One caveat worth writing down: the federal GFE rules are a floor, not a ceiling. Some states add their own disclosure requirements, and a plan can ask for information the federal rule does not mention. When a client’s situation sits between the two, confirm with the payer and with your state licensing board before you rely on a template alone.

A notice of the right to a GFE also has to be posted on the practice website, in the office, and at the point of scheduling, and communicated both orally and in writing. CMS publishes a model notice (CMS-10791).

The app only sends your license key and a device id to our license check (which asks Creem) — no patient or practice data ever leaves your browser.

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