Transparency in Coverage: The New Rules on Surprise Billing and Good Faith Estimates (45 CFR Part 149)

The No Surprises Act, implemented at 45 CFR Part 149, reshaped how small practices communicate prices and protect patients from unexpected out-of-network bills. Two provisions directly affect daily clinic operations: the ban on certain surprise bills with limited notice-and-consent exceptions, and Good Faith Estimates (GFEs) for uninsured or self-pay patients, including the Patient-Provider Dispute Resolution (PPDR) pathway when billed charges considerably exceed the GFE. By operationalizing disclosures, time-bound GFE production, co-provider coordination, and PPDR readiness, small practices can reduce complaints, avoid enforcement risk, and build trust with patients before services occur.

Patients want to know, “How much will this cost?” Regulators want to ensure they are not surprised by out-of-network charges they did not choose. 45 CFR Part 149 delivers both goals: it prohibits balance billing in key settings and requires providers to furnish GFEs to uninsured or self-pay individuals before services are rendered. For small clinics, the challenge is not interpreting the law but installing a light-weight workflow that produces disclosures and estimates on time, coordinates with other clinicians involved in the service, and documents everything in case a PPDR is initiated. This article converts Part 149 into clinic-ready steps that align scheduling, front desk, and billing.

Legal Framework & Scope Under 45 CFR Part 149

Surprise billing protections. Part 149 bars certain out-of-network balance bills for emergency services, for post-stabilization services until appropriate notice-and-consent conditions are met, and for non-emergency services furnished by out-of-network providers at in-network facilities where the patient had no meaningful choice. Limited exceptions allow notice-and-consent in some non-emergency scenarios, but many ancillary services (e.g., certain anesthesiology, radiology, pathology) are not waiver-eligible. Providers must also give a standard disclosure that describes patient protections and how to report violations.

Good Faith Estimates (GFEs) for uninsured/self-pay individuals. Under 45 CFR 149.610, when a patient is uninsured or chooses not to submit a claim to insurance (self-pay), providers must offer a GFE before the service. The GFE must list expected charges for all items and services reasonably expected for the episode, including from co-providers and co-facilities when the clinic is the convening provider. The estimate must use plain language, itemize services, and include identifiers, diagnosis/procedure codes where known, and disclaimers about variability.

Patient-Provider Dispute Resolution (PPDR). If the actual billed charges exceed the GFE by more than a specified threshold, the patient may seek PPDR under 45 CFR 149.620 within the permitted filing window. The process is administered by a selected entity, and both patient and provider must submit documentation (including the GFE and any supporting rationale). A small practice that keeps a clean GFE file can respond efficiently and mitigate exposure.

Why this matters for denials and friction. Clear pre-service estimates and proper disclosures reduce downstream disputes, complaints, and refund requests. Aligning clinic timelines to 149.610 and documenting notice-and-consent exceptions under 149.410–149.420 avoids enforcement risk and saves staff time otherwise spent on post-service wrangling.

Federal oversight. HHS (through CMS and related offices) enforces provider compliance for No Surprises Act requirements codified in 45 CFR Part 149. The Federal Register rulemakings and subsequent guidance set expectations for disclosure content, GFE format and timing, and PPDR documentation. For insured patients, additional payer-facing transparency requirements exist, but provider duties in this article center on Part 149.

Common review triggers.

• Patient complaints alleging missing or late GFEs or absent standard disclosures.

• Bills for non-emergency services at an in-network facility that appear to balance bill without valid notice-and-consent.

• PPDR submissions demonstrating a large variance from the furnished GFE, with poor provider documentation of assumptions or co-provider coordination.

• Patterns of failure to coordinate with co-providers when the clinic acted as the convening provider.

Evidence regulators expect. A standard disclosure posted and handed out, a GFE log tied to scheduling dates and production deadlines, copies of GFEs with all required elements, documentation of co-provider outreach, and, if applicable, properly completed notice-and-consent forms for waiver-eligible services.

Each control below is sized for lean teams and tied directly to 45 CFR Part 149 requirements.

1) Standard Disclosure Everywhere Patients Enter

• Implement: Deploy the required No Surprises Act disclosure at the front desk, website homepage footer (or billing page), patient portal, and appointment confirmations. Train staff to hand out the disclosure on first contact for self-pay or when a patient asks about costs.

• Evidence: Dated signage photos, PDF of website page, onboarding script, and a checkbox in the intake form.

• Low-cost: One-page disclosure template with your contact info and complaint channels.

• Why it maps to Part 149: Satisfies provider disclosure obligations and sets expectations before fees are discussed under Subpart E standards.

2) Two-Timer GFE Clock Aligned to Scheduling

• Implement: Tie GFE production to appointment timing. If services are scheduled at least 3 business days out, generate the GFE within 1 business day of the request; for 10 or more business days out, generate within 3 business days. If the patient requests a GFE without scheduling, apply the appropriate clock based on the request date and anticipated service date.

• Evidence: Timestamped GFE log with “request date,” “scheduled date,” and “GFE sent date.”

• Low-cost: A column in your scheduling spreadsheet; automated reminder rules.

• Why it maps to Part 149: Implements the 149.610 production deadlines.

3) Convening Provider Intake for Co-Provider Charges

• Implement: When your clinic is the convening provider, capture anticipated co-providers (e.g., lab, imaging, anesthesia) at intake and send a one-page estimate request the same day; follow up at D+1 and D+3 if no response. If a co-estimate is still pending, include a clear placeholder line with best-known ranges and a note that a revised GFE will follow once data arrive.

• Evidence: Outbound requests, responses (or lack), and versioned GFEs showing updates.

• Low-cost: Email template with standard fields; shared tracker.

• Why it maps to Part 149: Reflects 149.610 duties for convening providers to aggregate reasonably expected items and services.

4) GFE Content Builder: Make It Scannable

• Implement: Standardize your GFE to include patient identifiers, service date(s), diagnosis/procedure codes if known, line-item descriptions, unit counts, and projected charges; add required disclaimers and the PPDR notice language. Keep the narrative to a crisp paragraph and rely on the online items for clarity.

• Evidence: Saved PDFs with version numbers; template control list cross-checked at filing.

• Low-cost: A locked Word template exporting to PDF.

• Why it maps to Part 149: Ensures all 149.610 content elements are present.

5) Notice-and-Consent Exception Guardrails

• Implement: For non-emergency out-of-network services at in-network facilities, enable a checklist to determine whether the service is waiver-eligible and, if so, present the notice-and-consent form within the required timeframe and format. Block waiver attempts for non-waivable ancillary services.

• Evidence: Completed forms when permitted; “blocked” log entries when not permitted.

• Low-cost: Laminated matrix of waiver-eligible vs non-waivable services.

• Why it maps to Part 149: Aligns with 149.410–149.420 on balance billing prohibitions and exceptions.

6) PPDR Readiness Packet

• Implement: Pre-stage a PPDR folder that includes the original GFE, all versions, proof of delivery to the patient, any co-provider outreach records, and a one-page rationale explaining major cost drivers. If a bill will exceed the GFE, proactively communicate and issue a revised GFE as appropriate.

• Evidence: Folder with exhibits A–F; email showing revised estimate sent before service when possible.

• Low-cost: A single “PPDR exhibits” checklist attached to the GFE template.

• Why it maps to Part 149: Supports the PPDR pathway under 149.620 and demonstrates good-faith compliance.

7) Digital + Phone Scripts for Cost Conversations

• Implement: Add a two-minute script for staff: confirm uninsured/self-pay status; offer the GFE; explain variability drivers; point to the disclosure and, where applicable, the notice-and-consent process rules.

• Evidence: Script in the training binder; call log notation “GFE offered.”

• Low-cost: One training slide; monthly 10-minute refresher.

• Why it maps to Part 149: Improves consistent delivery of 149.610 rights and disclosures.

8) Estimate Revision Triggers

• Implement: Create triggers for revised GFEs when the scope changes (e.g., additional tests or higher level of service becomes reasonably expected). Send the revision promptly with a short explanation.

• Evidence: Revised GFE with timestamp and a “reason for revision” line.

• Low-cost: Dropdown list of common revision reasons in your template.

• Why it maps to Part 149: Keeps the GFE “reasonable” in light of known changes, consistent with 149.610.

Case Study

A small cardiology practice schedules an uninsured patient for a diagnostic stress test and echo in two weeks. The front desk confirms self-pay status and triggers the two-timer GFE clock. Within one business day, the clinic issues a GFE itemizing the cardiologist professional fee, facility fee, and anticipated technical components. Acting as the convening provider, the clinic also emails the affiliated imaging center for its portion and follows up at D+1 and D+3; when the imaging center delays, the clinic sends the GFE with the clinic’s items and a clearly labeled placeholder for imaging, including a range based on prior rate sheets and a disclaimer that a revised GFE will follow. Three days later, the imaging center responds; the clinic issues an updated consolidated GFE.

On service day, the patient tolerates testing poorly, and the physician deems an additional limited echo view necessary. The clinic emails a revised GFE addendum that afternoon, noting the small scope change. The final bill comes within the expected bands and the patient pays without dispute. Months later, a different uninsured patient’s bill exceeds their GFE by a large margin because a second unanticipated study was performed. The patient initiates PPDR. The clinic furnishes the original and revised GFEs, time-stamped communications, and clinical notes explaining why the extra study became reasonably necessary. The PPDR entity reviews and determines an adjusted patient amount based on the GFE and submitted rationale. Because the clinic had clear documentation and timely GFE updates, the finding reflects a modest adjustment with no penalty or further action.

Risk Traps & Fixes Under 45 CFR Part 149

Small practices most often stumble on timing and documentation, both are solvable with short checklists and a shared tracker.

• Trap: Issuing a GFE only at checkout. Fix: Start the GFE clock at the first scheduling or cost inquiry and send within the 1- or 3-business-day windows required by 149.610; log timestamps to prove timeliness.

• Trap: Ignoring co-providers when acting as the convening provider. Fix: Send D0 estimate requests and D+1/D+3 follow-ups; if data lag, include labeled placeholders and issue a revised GFE once figures arrive to remain aligned with 149.610.

• Trap: Using notice-and-consent for non-waivable ancillary services. Fix: Maintain a waiver matrix and block consents where 149.410–149.420 prohibit them; submit only valid waivers within the required timeframes and format.

• Trap: Vague GFEs that lack itemization, codes, or disclaimers. Fix: Use the GFE Content Builder with required elements and plain-language descriptions per 149.610; include variability disclaimers and contact info.

• Trap: No PPDR file or revision trail when scope changes. Fix: Pre-stage a PPDR exhibits folder and issue revised GFEs promptly upon scope shifts; this supports your position if 149.620 is invoked.

• Trap: Disclosure posted online but not handed to patients. Fix: Train front desk to provide the standard disclosure during intake and attach it to appointment confirmations, satisfying Part 149 provider disclosure expectations.

When these fixes are implemented, clinics meet the core transparency duties, reduce patient friction, and position themselves to defend decisions if a PPDR occurs.

Keep governance simple and visible. Assign a Transparency Champion (often the billing lead) to own the templates, the GFE log, and monthly audits. Run a 10-minute huddle each week to review two metrics: on-time GFE rate and percent of services with complete co-provider data at the time of estimate. Provide a one-slide refresher quarterly on notice-and-consent eligibility, and keep the waiver matrix up to date. Tie staff performance to these small, controllable behaviors rather than outcomes you cannot control, such as payer pricing changes.

Transparency is not a paperwork chore; it is a clinic’s best defense against complaints and post-service disputes. 45 CFR Part 149 makes providers the first line of clarity by requiring standard disclosures and timely, itemized GFEs for uninsured or self-pay individuals, plus careful use of notice-and-consent when allowed and preparedness for PPDR. With a slender toolkit, disclosure posting, two-timer GFE clocks, co-provider outreach, and PPDR readiness, small practices can meet the rule’s letter and spirit without adding headcount.

Concrete next steps for the next 7 days

• Deploy the GFE & NSA Packet Builder and insert it into the scheduling workflow.

• Turn on the two-timer reminders in your calendar or EHR message rules for 1-day and 3-day GFE deadlines.

• Create the co-provider request email template and D0/D+1/D+3 cadence; add a placeholder protocol.

• Print the waiver eligibility matrix and train front desk to block non-waivable consents.

• Assemble the PPDR readiness folder and map where each exhibit will come from in your clinic.

• 45 CFR Part 149 — Requirements Related to Surprise Billing, Price Transparency, and Other Patient Protections

• 45 CFR 149.410 and 149.420 — Notice and Consent Requirements; Prohibitions on Balance Billing

• 45 CFR 149.610 — Good Faith Estimates for Uninsured or Self-Pay Individuals

• 45 CFR 149.620 — Patient-Provider Dispute Resolution (PPDR) Process

• HHS/CMS Guidance on No Surprises Act Provider Requirements