The Price Transparency Rule: Are You Posting Your Good Faith Estimates Correctly? (45 CFR Part 149)

The No Surprises Act, implemented at 45 CFR Part 149, requires providers and facilities to give uninsured or self pay patients a written Good Faith Estimate of expected charges when services are scheduled or when an estimate is requested.  For small practices, this is the core price transparency rule that patients feel in real life, much more than hospital machine-readable files or complex payer tools. If you accept cash pay, care for patients who are between plans, or see individuals who choose not to use insurance, you are on the hook for these estimates.

Under 45 CFR 149.610, a Good Faith Estimate must include specific content, follow tight timelines, and be kept as part of the medical record.  If the final bill for a provider or facility is at least 400 dollars higher than the GFE, the uninsured or self pay patient can initiate the federal patient provider dispute resolution process under 45 CFR 149.620. 

In parallel, providers must post clear information, including on their websites and in their offices, about patients’ rights to receive a Good Faith Estimate.  For a small clinic, getting the “posting plus GFE” combination right reduces disputes, builds trust, and helps avoid regulatory attention or reputational damage.

Price transparency can feel abstract until a patient challenges a bill that is hundreds of dollars higher than what they expected. That is exactly the scenario Congress attempted to address with the No Surprises Act’s Good Faith Estimate provisions. These rules do not only apply to hospitals or large systems. State licensed providers in small offices are required to issue GFEs to uninsured or self pay individuals, even when they are solo practitioners. 

For small practices, the operational pain points are predictable. Staff might not know when a GFE is required, what content it must include, or how quickly it must be delivered. Websites may talk generally about “affordable prices” without clearly stating that patients have a right to a written Good Faith Estimate. Appointment schedulers may quote “ballpark” numbers on the phone that do not match the GFE or final bill.

This article walks through the legal framework of 45 CFR Part 149, then focuses on practical controls that allow a small clinic to comply without sophisticated software. The emphasis is on being able to prove that your practice issues correct GFEs, posts the right notices, and responds appropriately when billed charges diverge from expectations.

Understanding Legal Framework & Scope Under 45 CFR Part 149

45 CFR Part 149 implements key price protection provisions of the No Surprises Act, a component of the Consolidated Appropriations Act, 2021. The part is divided into multiple subparts, including protections against surprise billing, provider requirements, an independent dispute resolution process, and protections for uninsured or self pay individuals. 

Good Faith Estimates for uninsured or self pay individuals are located in Subpart G, “Protection of Uninsured or Self-Pay Individuals,” at 45 CFR 149.610.  Key concepts include:

• The requirement applies when an individual is uninsured or self pay, including those who are not enrolled in a plan and those who choose not to submit a claim for an item or service.

• A GFE must be provided when an uninsured or self pay individual schedules an item or service, or requests an estimate, within defined business day timelines.

• The convening provider or facility is responsible for obtaining expected charges from co-providers or co facilities and issuing a consolidated GFE in many scenarios.

Content requirements are detailed in 149.610(c) and supplemented by CMS guidance. A compliant GFE must include, among other elements, a description of the primary item or service, an itemized list of reasonably expected related items and services, diagnosis codes, expected service codes, expected charges, and specific disclaimers about variation, the right to dispute charges, and the non-contractual nature of the GFE. 

The patient provider dispute resolution process in 45 CFR 149.620 allows an uninsured or self pay individual to challenge a bill that is 400 dollars or more above the GFE for a provider or facility, subject to eligibility criteria and timelines. 

Federal rules set the floor. States may have additional price transparency, balance billing, or charity care requirements. When state rules are more protective of the patient, providers must meet the higher standard, but complying with 45 CFR 149.610 and 149.620 substantially reduces federal level risk and improves consistency in patient communications.

Multiple federal agencies share responsibility for enforcing No Surprises Act provisions, including those in 45 CFR Part 149. HHS, the Department of Labor, and the Treasury Department coordinate enforcement depending on whether the matter involves group health plans, issuers, or providers and facilities. For GFE obligations to uninsured or self pay individuals, HHS, through CMS and related components, is the primary enforcer. 

Common enforcement or review triggers relevant to Good Faith Estimates include:

• Complaints filed by uninsured or self pay individuals who were not offered a GFE when scheduling or requesting services, or who were billed substantially more than the estimate without explanation.

• Patterns revealed through the patient provider dispute resolution process, where SDR entities see repeated cases involving the same clinic or demonstrate systemic failure to issue or honor GFEs.

• Market conduct or oversight reviews where regulators examine a sample of GFEs, posted notices, and dispute outcomes in a region or specialty.

Outcomes can range from technical assistance to corrective action plans, civil monetary penalties for certain violations, and reputational damage through publicized enforcement actions. For a small practice, misunderstanding GFE rules or treating them as optional can turn a simple billing complaint into an expensive dispute that undermines cash flow and patient trust.

Although the heading refers to HIPAA, these survival steps focus on aligning your Good Faith Estimate processes with 45 CFR Part 149 so that any audit or inquiry is easier to manage. Each control is designed for small practices with limited budgets and ties directly to specific regulatory citations.

First, clinics need a simple way to identify when a GFE is required. A short decision tool used at scheduling and check in can prevent missed opportunities.

• Implementation: Build a two question script for schedulers and front desk staff: (1) “Do you have health insurance?” and (2) “Do you plan to use it for this visit?” If the patient is uninsured or chooses not to use coverage, flag the encounter as GFE required. Link that flag to a workflow that generates a GFE under 45 CFR 149.610(a) and (b).

• Evidence: Retain call scripts, screenshots of scheduling system fields, and samples of completed GFE flags. Showing that you consistently ask these questions is critical if a patient later alleges you failed to offer a GFE.

• Low cost: Use existing scheduling templates and simple checkboxes instead of new software, and store scripts in your existing training binder or intranet.

Second, your practice should standardize timing and delivery to meet the regulatory deadlines. Patients and regulators care as much about when the GFE is given as what it says.

• Implementation: Create a timing matrix for GFEs that tracks the requirements in 45 CFR 149.610(b). For example, if a service is scheduled at least 10 business days away, the GFE must be provided within 3 business days; if scheduled at least 3 but less than 10 business days away, within 1 business day; and if the patient requests a GFE without scheduling, within 3 business days. Configure reminders or tasks in your practice management system to match these windows.

• Evidence: Maintain logs or task reports that show GFE issuance dates relative to scheduling or request dates, along with sample GFEs.

• Low cost: Use calendar reminders or basic task features in your existing system instead of purchasing a dedicated workflow tool.

Third, develop a reusable Good Faith Estimate template library that embeds the 45 CFR 149.610(c) content requirements. This reduces the risk of leaving out critical data elements.

• Implementation: Starting from the CMS model GFE and data element appendix, build templates for your top self pay services that include required fields such as patient identifiers, diagnosis codes, service codes, itemized expected charges, and the mandatory disclaimers about variability, dispute rights, and non-contractual status.

• Evidence: Store blank templates and completed examples for each service category. During an audit, these demonstrate that your clinic has institutionalized the regulatory content in its forms.

• Low cost: Create templates in word processing or PDF software you already own and print or email them as required by 149.610(e).

Fourth, align your posting practices with GFE rights, so patients know to ask for estimates and understand how to challenge bills.

• Implementation: Place a concise “Right to Receive a Good Faith Estimate” notice in your waiting area, on your website, and in new patient packets, using language consistent with CMS and HHS model notices. The notice should explain who qualifies, when a GFE is issued, and how to access the patient provider dispute resolution process if billed charges exceed the estimate by 400 dollars or more.

• Evidence: Keep dated screenshots of your website, photographs of posted signs, and copies of printed materials to prove continuous posting.

• Low cost: Use simple printed posters and a basic web page instead of custom design work; the clarity of the message matters more than aesthetics.

Fifth, track and respond to GFE related disputes in a structured way, with the PPDR process in mind.

• Implementation: Add a “GFE variance” section to your billing or compliance log, recording cases where the final bill is substantially higher than the estimate and noting whether the patient raised concerns. Train staff to escalate cases that may be eligible for the federal patient provider dispute resolution process under 45 CFR 149.620 and to offer explanations or corrections early.

• Evidence: Keep a log of GFE variances, correspondence with patients, and any adjustments or payment plans established. This record can be powerful if regulators question how your practice handles disputes.

• Low cost: Use the same spreadsheet or logging tool you already employ for denials or complaints, simply adding columns specific to GFE issues.

Taken together, these controls give a small practice a GFE framework that can withstand external scrutiny. They are intentionally light on technology requirements and heavy on documentation that shows regulators your clinic took the price transparency rules under 45 CFR Part 149 seriously.

Case Study

A three physician primary care clinic in a suburban area sees a growing number of patients who are uninsured between jobs or who decide to pay cash for predictable services like annual exams and simple procedures. The clinic posts a friendly “ask us about our cash pay discounts” sign and lists some ballpark prices on its website, but it has not built a formal Good Faith Estimate process.

An uninsured patient schedules a minor in office procedure two weeks in advance. During scheduling, staff quote “around 350 dollars” based on a rough average. No written Good Faith Estimate is provided. The visit includes additional lab work, and the final bill is 850 dollars. The patient is surprised and files a complaint, pointing to online information about the right to a Good Faith Estimate and the federal dispute process.

Regulators review the complaint under 45 CFR 149.610 and 149.620. They determine that:

• The patient was uninsured and thus eligible for a Good Faith Estimate when the procedure was scheduled.

• The clinic failed to provide a written GFE within 3 business days of scheduling, despite having more than 10 business days before the appointment.

• The billed charges for the procedure and related services were more than 400 dollars above what a reasonable GFE would have shown, making the case eligible for the patient provider dispute resolution process.

Through the PPDR process, an SDR entity reviews the clinic’s usual charges and what the GFE should have contained. The entity determines that a lower amount is appropriate, and the clinic must refund the difference. The clinic also spends staff time gathering records and working with counsel, losing more than the refunded amount in productivity and fees. Patients in the community quickly learn that the clinic “overbilled” someone, which harms the clinic’s reputation.

If the clinic had followed the survival guide controls, the outcome could have been very different. A scheduler using the two question script would have flagged the patient as uninsured, and a template based GFE would have been issued within 3 business days, capturing expected lab work and including the mandatory disclaimers. Variances would have been tracked in a log, and staff could have offered to correct any large gap before the patient sought federal dispute resolution. The clinic would have looked prepared and transparent, reducing the chances of a contentious outcome.

The following checklist supports lean, practical oversight of Good Faith Estimate and posting obligations under 45 CFR Part 149. Clinics can complete it annually or semi-annually.

Completing this table on a regular schedule keeps GFE and posting obligations visible and actionable. It also provides a simple evidence trail that your clinic is actively managing the requirements of 45 CFR Part 149 rather than reacting only when disputes arise.

Common Audit Pitfalls to Avoid Under 45 CFR Part 149

When regulators, payers, or dispute resolution entities look at a small practice’s GFE program, they often see the same mistakes. Understanding these pitfalls can help you prioritize fixes that directly reduce compliance risk under Part 149.

• Treating verbal ballpark quotes as enough, even though 45 CFR 149.610 requires to be written Good Faith Estimates in paper or electronic form within specific timelines for uninsured or self pay individuals; this can lead to patient complaints and unfavorable dispute outcomes.

• Assuming that posting a generic cash price list on the website satisfies federal obligations, while failing to issue individualized GFEs that include diagnosis codes, service codes, and required disclaimers under 149.610(c).

• Not coordinating with co providers or co facilities, resulting in GFEs that omit significant expected charges, which increases the likelihood that billed charges will exceed the estimate by 400 dollars and trigger the patient provider dispute resolution process.

• Forgetting to update GFEs when there are material changes in planned services or pricing, even though CMS guidance and 45 CFR 149.610(b)(1)(vii) expect updated estimates when the care plan shifts.

• Failing to keep GFEs as part of the medical record for the required retention period, which makes it difficult to defend your practice in a dispute or audit because you cannot prove what the patient was shown.

By addressing these pitfalls, small practices can significantly reduce the chances of landing in the patient provider dispute resolution process and can better defend their billing when challenged. The fixes also make financial conversations clearer for patients, which supports both compliance and collection performance.

A sustainable GFE program does not require a new department, but it does demand clear ownership and simple rhythms. The practice should designate an existing leader, often the practice manager or compliance lead, as the point person for No Surprises Act and GFE compliance, with authority to update scripts, templates, and notices as guidance evolves. 

Training can be light but recurring. New front desk and scheduling staff should receive a short orientation on when GFEs are required, how to use the templates, and how to talk to patients about estimates and dispute rights. Once a year, a brief refresher for all relevant staff, using one or two real cases from your clinic’s own variance log, keeps the rules alive and grounded in daily work. 

Monitoring should focus on a few meaningful indicators: the number of GFEs issued per quarter, the percentage issued on time, the number of disputes or complaints involving estimates, and how often the patient provider dispute resolution process is invoked. Reviewing these metrics at leadership meetings and documenting follow-up actions creates a governance trail that regulators will recognize as evidence of a serious, good faith compliance effort.

Good Faith Estimates are the front line of price transparency for small ambulatory practices. The legal requirements at 45 CFR 149.610 and 149.620 may be technical, but they boil down to a few practical duties: ask the right questions to identify uninsured or self pay patients, issue timely written estimates with required content, post clear notices of rights, and respond constructively when bills deviate from estimates. 

To move from theory to action, small clinics can focus on these immediate steps:

1. Update scheduling and intake scripts so that every patient is screened for GFE eligibility and eligible encounters are flagged automatically.

2. Build or refine a set of Good Faith Estimate templates that cover your most common self pay services and incorporate all required data elements and disclaimers from 45 CFR 149.610(c).

3. Confirm that your website and waiting room signage clearly communicate patients’ rights to receive a GFE and explain how to request one and where to go if billed far above the estimate.

4. Create or update a GFE variance and dispute log and use it to spot patterns in billing that may cause friction or regulatory interest.

5. Assemble a small GFE documentation packet, including policies, templates, sample GFEs, and logs, so you are ready to respond if CMS or another regulator asks how your practice complies with Part 149.

Recommended compliance tool: 

A shared “GFE Toolkit” folder that stores your templates, scripts, variance log, and posting screenshots in one place, mapped to each subsection of 45 CFR 149.610 and 149.620.

Advice: 

In your next staff huddle, pick one recent self pay patient and walk through whether a compliant Good Faith Estimate was offered, documented, and stored; treat any gaps you find as your first transparency fix.

• 45 CFR Part 149 – Surprise Billing and Transparency Requirements
  

• 45 CFR 149.610 – Requirements for Provision of Good Faith Estimates of Expected Charges for Uninsured (or Self-Pay) Individuals
  

• 45 CFR 149.620 – Requirements for the Patient-Provider Dispute Resolution Process
  

• Requirements Related to Surprise Billing; Part II, Interim Final Rule