Under federal rules, a patient with insurance can still count as "self-pay" if they choose not to have a claim sent to their plan. For practices built on memberships, packages and cash visits, that can bring a large share of the schedule under the good faith estimate rules.
Who counts as self-pay
The rule at 45 CFR 149.610 covers 2 groups. The first is people with no coverage for the service. The second is people who have coverage but do not want a claim submitted to their plan.
The requirements have applied to estimates requested, or services scheduled, on or after January 1, 2022.
Because the rule ties these steps to scheduling, the simplest fix is to build 2 questions into your booking script: does the patient have coverage, and do they want a claim sent to it?
When you must tell patients
The scheduling practice must ask whether the patient has coverage and whether they want a claim submitted. Self-pay patients must then be told that a good faith estimate is available.
That notice has to be written clearly and displayed on your website, in the office and where scheduling happens. It must also be given out loud when a visit is booked or when someone asks about cost.
The notice must also be available in accessible formats and in the languages your patients speak.
One detail is easy to miss. Any discussion or question about the potential cost of a service counts as a request for an estimate.
Deadlines that start at booking
The clock runs from the date of scheduling or the request, not the date of the visit.
- Booked at least 3 business days ahead: estimate due within 1 business day of scheduling
- Booked at least 10 business days ahead: estimate due within 3 business days of scheduling
- Requested by the patient: estimate due within 3 business days of the request
If the expected services or charges change, a new estimate is due no later than 1 business day before the visit.
What the estimate must include
- Patient name and date of birth
- A plain description of the main service and its scheduled date
- An itemized list of expected services with diagnosis codes, service codes and expected charges
- Name, NPI, tax ID and location of each provider or facility listed
- Disclaimers that it is an estimate, that other services may be recommended, that it is not a contract, and that the patient may dispute a bill
The estimate must be in writing, on paper or electronically, based on what the patient asks for. An electronic copy has to be one the patient can save and print.
Packages and recurring visits
A single estimate can cover recurring services, such as a monthly program. It must state the expected scope, including timeframes, frequency and total number of visits, and it cannot cover more than 12 months.
Each estimate becomes part of the patient's medical record. Patients can ask for a copy of any estimate issued in the last 6 years.
Fixing a wrong estimate
Mistakes happen. If you learn that an estimate was incomplete or inaccurate, the rule says to give the patient corrected information as soon as practicable.
If the service is provided before the error is fixed, the bill can still go to dispute when it lands $400 or more above the estimate. A state estimate form that does not meet the federal requirements does not satisfy them either.
When patients can dispute
Under 45 CFR 149.620, a bill is eligible for dispute when a provider's total billed charges are at least $400 more than the total expected charges on that provider's estimate.
The patient has to start the process within 120 calendar days of receiving the first bill with those charges, and pays an administrative fee.
If outside providers or facilities, such as a lab, are part of the service, more requirements apply. Talk to your compliance advisor about how the rules and current HHS guidance apply to your setup.
In EMR MD, a copy of each estimate can be stored in the patient's chart with other documents, which keeps it with the record the rule says it belongs to.
Sources
- 45 CFR 149.610: Requirements for provision of good faith estimates of expected charges for uninsured (or self-pay) individuals Electronic Code of Federal Regulations (eCFR), 2026
- 45 CFR 149.620: Requirements for the patient-provider dispute resolution process Electronic Code of Federal Regulations (eCFR), 2026
This article is general information, not legal or medical advice. Rules change; check the source and your compliance advisor before acting.