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The No Surprises Act and Good Faith Estimates

November 15, 2021

Effective January 1, 2022, health care providers and facilities will be required to provide a Good Faith Estimate of expected charges for all items and services upon request or scheduling. Items or services include everything provided or assessed in connection with the provision of health care: all encounters, procedures, medical tests, prescription drugs, durable medical equipment and related fees. The Department of Health and Human Services (“HHS”) has advised that the definition of items and services include those related to dental health, vision, substance use disorders and mental health.

Under the new rules, if a patient is planning to submit a claim for an item or service to their health plan, then a Good Faith Estimate must be provided to the health plan. Upon receiving the estimate, the plan will be required to provide an advanced explanation of benefits notification. The notification must include the network status of the provider or facility, the contracted rate, the good faith estimate received from the provider, estimated insurer and patient responsibility, and certain disclaimers. HHS is planning to delay enforcement of these requirements until further implementing regulations have been issued.

However, if the patient is either uninsured, or does not want to submit a claim to their plan (“self-pay”), then a Good Faith Estimate must be provided directly to the patient. Enforcement of this requirement to provide an estimate to uninsured and self-pay patients will begin January 1, 2022. Some of the requirements of the Good Faith Estimate include providing:

  • An estimate of all charges for all items and services that are reasonably expected to be provided with the primary item or service;
  • The cash pay rate or rate established by a provider or facility for uninsured or self-pay or the amount the provider or facility would expect to charge if the provider or facility intended to bill a plan or issuer directly;
  • A list of all applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service;
  • The name, NPI, and TIN of each provider or facility and the location where the items or services will be furnished; and
  • Disclaimers that inform the patient of the potential for additional items or services that are not reflected in the estimate and providing instructions regarding the dispute resolution process.

If there are multiple providers and facilities that will provide services in conjunction with the primary service or item, then the facility or provider responsible for scheduling the primary service must coordinate and provide the estimate. The patient must receive an itemized list that is grouped by provider, and the estimate must clearly describe the primary item or service.

Weaver Johnston & Nelson, PLLC will be providing summaries and updates regarding these changes and as more guidance becomes available. For questions about the No Surprises Act or assistance with implementing these new requirements, contact Chris Reed at creed@weaverjohnston.com.