No Surprises Act Good Faith Estimate generator for cash-pay clinics

01When your practice must give a Good Faith Estimate

The rule covers uninsured or self-pay individuals. Under § 149.610 that means a patient with no coverage for the service, or a patient who has coverage but does not want a claim sent to the plan. For a cash-pay or out-of-network integrative gynecology practice, that is most of your schedule — including insured patients who will file their own superbill later.

You owe a written estimate in three situations, counted in business days:

Table 1 · Source: 45 CFR § 149.610(b)(1)(vi). Any discussion or question about cost counts as a request.

That last point catches many practices. Under § 149.610(b)(1)(iv), when a patient asks “what will this cost?” on the phone, that is a request for a Good Faith Estimate. You must also tell uninsured and self-pay patients that estimates are available: in a clear notice on your website, in the office and where scheduling happens, and when they book or ask about cost.

The estimate has to be in writing, on paper or electronically as the patient prefers, and an electronic copy must be one the patient can save and print. It becomes part of the medical record, and you must give a copy of any estimate issued in the last 6 years if the patient asks. The generator’s deadline badge reads your scheduling date and service date and tells you which rule applies and the due date. It counts Monday to Friday, so adjust if your office closes on a holiday inside the window.

Building these steps into intake is part of opening a cash-pay practice; the OB/GYN practice transition blueprint puts the Good Faith Estimate workflow alongside your fee schedule, contracts and front-desk scripts.

02What § 149.610(c)(1) requires on every estimate

An estimate that leaves out a required element can be treated as not meeting the rule. Each one maps to a section of the generator:

(i) Patient

Name and date of birth.

(ii) Primary service

A description in clear, understandable language and, if scheduled, the date. Write “new-patient visit, about 60 minutes, with a pelvic ultrasound”, not only 99205 and 76830.

(iii) Itemized list

Items and services reasonably expected for that period of care, grouped by provider: yours first, then any co-provider or co-facility.

(iv) Codes and charges

Applicable diagnosis codes, expected service codes and the expected charge for each line. If no diagnosis has been made before the first visit, many practices write “pending clinical evaluation”; confirm current CMS guidance.

(v) Identifiers and location

Name, NPI and tax identification number of each provider or facility, and the state and office or facility location where care is expected.

(vi) Separately scheduled items

A list of items you expect to need separate scheduling — outside labs, pathology, a compounding pharmacy — with a disclaimer directly above it saying separate estimates will be issued, that codes and charges are not required for those items, and how to get those estimates.

(viii)–(xi) Four disclaimers

Other recommended care may be scheduled separately; this is only an estimate and actual charges may differ; the right to patient-provider dispute resolution, with where to find information and a statement that disputing will not affect the quality of care; and that the estimate is not a contract.

Paragraph (vii) is reserved, which is why the disclaimers start at (viii). The generator prints all four disclaimers in plain English on page 2, with the CMS help line and website, and fills in the dollar figure at which your own bill would cross the dispute threshold.

03The $400 dispute threshold and how to price your estimate

The estimate matters most after the visit. Under 45 CFR § 149.620, if a provider’s final bill is at least $400 more than that provider’s total on the Good Faith Estimate, the patient can start the federal patient-provider dispute resolution process. They have 120 calendar days from receiving the first bill to do so and pay a small administrative fee set by HHS. An independent reviewer then decides what the patient owes.

The threshold is per provider or facility, not per line. If your estimate totals $720, a final bill of $1,120 or more from your practice could be disputed. The generator shows that number for you and for any co-provider as you add lines, and prints it in the dispute disclaimer so the patient sees the same figure.

Three habits keep you well inside it:

• List everything you reasonably expect, not just the visit. If you usually draw labs in the office, put the 36415 venipuncture on the estimate.
• Use your real self-pay prices. Our 2026 clinic pricing benchmark found a median published initial consultation of $297.50 (middle half $250–$445) across 16 clinics, which is a useful sense check.
• Issue a new estimate when the plan changes. If you expect a change in scope, charges or providers for scheduled care, § 149.610 requires a new estimate no later than 1 business day before the service.

To see how self-pay visit prices and memberships add up across a full panel, model them in the practice transition simulator with a 300-member panel at $200 a month.

04Recurring care plans, co-providers and outside labs

Integrative gynecology care is rarely a single visit, and the rule has specific provisions for that.

Recurring visits

You may issue one estimate for recurring primary services — for example an intake and three hormone follow-ups. It must state the expected scope in plain terms (timeframe, frequency and total number of visits) and cannot cover more than 12 months. The annual hormone care plan template fills a 12-month scope you can edit; the generator warns you if a line has a quantity above 1 and no scope.

Co-providers and co-facilities

If another provider or facility will furnish services as part of the same period of care, the rule makes you the convening provider: you request their estimate information within 1 business day, and they owe it back within 1 business day of your request. Their lines, NPI and TIN then appear in their own group. HHS has used enforcement discretion on including co-provider and co-facility information in estimates for uninsured and self-pay patients while it works on further rules, so check current CMS guidance before relying on that. Tick “Add a co-provider” to print the second group.

Outside labs, pathology and pharmacy

Reference-lab testing, pathology on a biopsy and prescriptions filled at a retail or 503A compounding pharmacy are usually scheduled and billed separately. List them in the separately scheduled section, with the instructions for getting those estimates, so the patient is not surprised by a second bill.

If you are closing an insurance-based practice to open a cash-pay one, the practice transition letter and Medicare opt-out contract generator covers the patient notices you will send at the same time, and the Hint vs Cerbo vs Elation comparison compares the practice systems you might use to keep signed estimates with each chart.

05How to use this generator at the front desk

1. Pick a quick template — a 60-minute new consult with ultrasound, an annual hormone care plan, an endometrial biopsy or an IUD insertion — then replace the sample prices with your own fee schedule.
2. Enter your practice once: legal name, clinician, NPI, TIN and service address. Save the filled PDF as your house template so staff only change the patient and scheduling fields.
3. Set the patient status and dates. Choose uninsured or self-pay, then the scheduling date and the service date, or “upon request”. Read the deadline badge.
4. Check the warnings, including missing codes, an NPI with a bad check digit or a recurring line without a scope.
5. Deliver it the way the patient asked, on paper or as a PDF they can save and print, and file a copy in the chart.

Prefer paper? Click Clear All Fields and print: every field prints as a blank line, while the required disclaimers stay in place. The generator gives you the structure; you remain responsible for accurate prices, on-time delivery and any state rules that add to the federal ones.

This page is educational and is not legal, billing or medical advice; confirm your obligations with healthcare counsel or current CMS guidance.