Good Faith Estimate Requirements & Best Practices for Behavioral Health

Overview: What You Need to Know About Good Faith Estimates

“Good Faith Estimates” (GFE) are actually valuable for the Provider because you can’t recover patient financial responsibility revenue if you don’t know what you are owed. However, in this white paper we will focus on GFE compliance requirements so Behavioral Health Providers can avoid compliance gaps that could result in Payer claim claw backs, enforcement actions, civil monetary penalties, and patient disputes.

Behavioral health and substance use disorder (SUD) providers are subject to the same federal “Good Faith Estimate” (GFE) requirements as all other healthcare providers under the No Surprises Act (effective January 1, 2022). These rules are enforced by the Centers for Medicare & Medicaid Services (CMS) and potentially in-network Payer contracts. These requirements apply regardless of whether the Provider participates in insurance networks. Here’s a breakdown of the compliance requirements that specifically impact behavioral health & SUD providers:

Who Must Provide a Good Faith Estimate

All licensed providers and facilities—including behavioral health centers, psychiatrists, psychologists, counselors, and SUD treatment programs—must provide GFEs upon request or before scheduled services as defined in the statute.

Applies whether the service is:

• In-Person

• Telehealth

• Virtual IOP/PHP/Residential Care

Which Patients Are Covered?

• Uninsured patients (self-pay).

• Insured patients who choose not to use insurance (for example, cash-pay for confidentiality in SUD treatment).

• GFEs are not required for patients using insurance benefits, since their financial liability is determined by EOBs,

though transparency practices are still encouraged because Providers are subject to individual State statutes.

Creating a GFE for all patients that is available upon request is the best protection from non-compliance of

Federal & State, and Payer requirements.

Timing Requirement Mandates

• If a service is scheduled ≥10 business days out → GFE due within 3 business days.

• If a service is scheduled 3–9 business days out → GFE due within 1 business day.

• If the patient requests an estimate without scheduling → must be provided within 3 business days.

• For recurring services (e.g., weekly therapy or residential treatment): providers may issue a single

GFE covering up to 12 months, with a clear scope of frequency/duration.

• For patients using commercial insurance there is no timing requirement, but having the estimate

available upon request is an industry best practice.

What Must Be Included

GFE must include:

• Provider/facility information.

• List of services/items reasonably expected for the course of treatment (diagnostic codes optional).

• Expected charges for each item/service (must be in “cash pay” amount or undiscounted rate).

• Ancillary items/services reasonably expected (e.g., lab tests, group therapy, MAT medication,

transportation & other uncovered services).

• Disclaimers, including:

o The GFE is only an estimate, and actual charges may differ.

o The patient has a right to dispute bills that are $400+ higher than the GFE through the HHS

patient-provider dispute resolution process.

Special Considerations for Behavioral Health & SUD

1. Variable Treatment Duration

Providers may not know at intake how long a patient will remain in treatment. CMS allows “expected scope” language (e.g., “Intensive outpatient program, 3 sessions/week for 8 weeks at $X/session”).

2. Changes in Plan of Care

If treatment changes significantly (e.g., move from IOP to residential), a new GFE must be issued.

3. Bundled Services

Residential or detox programs often include room/board, nursing, and therapy in a daily rate. This bundled per diem must be clearly itemized.

4. Third-party & Uncovered Services

(e.g., outside lab tests and transportation): The convening provider (usually the admitting facility) must try to include those in the GFE or note them as “to be billed separately.”

Documentation & Compliance

• Providers must keep a copy of all GFEs in the patient’s record (Electronic financial records are a good tool for this requirement).

• Must be delivered in written form (paper or electronic, depending on patient preference). Verbal estimates alone do not satisfy compliance.

• Noncompliance risks include HHS enforcement actions, civil monetary penalties, and patient disputes.

Summary for Behavioral Health/SUD Providers:

Under federal law, healthcare providers are required to give uninsured/self-pay patients (or insured patients opting out of insurance) a written good-faith estimate of charges, within strict timeframes, covering the expected scope of treatment. For unpredictable treatment (like detox, residential, or IOP), you must give a “best available” estimate, update it if treatment changes, and disclose patient rights. There are State laws that have more strict guidelines, including the requirement to provide a GFE for patients using commercial insurance. The most secure practice from a compliance perspective is to create a digital GFE that is available for all patients.

This white paper is not intended to be legal advice.

We recommend you discuss any questions or concerns regarding your compliance requirements with your legal counsel.