Good Faith Estimate Policy
Purpose
This policy ensures compliance with the federal No Surprises Act and provides uninsured or self-pay patients with a Good Faith Estimate (GFE) of expected charges for medical items and services before they receive care. The purpose is to promote transparency in healthcare costs and protect patients from unexpected medical bills.
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Policy Statement
USave Health is committed to providing clear, accurate, and timely estimates of the cost of care to all uninsured or self-pay patients. Patients have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency services, including related costs such as tests, procedures, and follow-up visits.
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Scope
This policy applies to all:
Uninsured patients (those without health insurance coverage).
Self-pay patients (those who choose not to use insurance for a service).
Scheduling staff, billing personnel, and clinical staff involved in estimating patient costs.
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Procedures
1. Patient Notification
Patients will be informed of their right to receive a Good Faith Estimate:
Verbally when scheduling an appointment.
In writing (paper or electronic) at least 1 business day before a scheduled service, or upon request.
2. Providing the Estimate
A written Good Faith Estimate will include:
Patient’s name and date of birth.
Description of the service(s) to be provided.
Itemized list of expected charges (professional fees, tests, procedures, etc.).
The name and NPI of each provider involved (if applicable).
Disclaimers explaining that the estimate is not a contract and that actual costs may vary.
Estimates are valid for 12 months from the date issued unless significant changes occur.
3. Timelines
If a service is scheduled at least 10 business days in advance, the estimate must be provided within 3 business days of scheduling.
If a service is scheduled at least 3 business days in advance, the estimate must be provided within 1 business day of scheduling.
If requested, a GFE must be provided within 3 business days of the patient’s request.
4. Revisions
Updated estimates must be provided if:
Additional services are anticipated.
Treatment plans change significantly.
Costs increase beyond the original estimate.
5. Dispute Resolution
If the actual bill exceeds the Good Faith Estimate by $400 or more, patients may file a dispute with the U.S. Department of Health and Human Services (HHS) within 120 days of receiving the bill.
Information on how to file a dispute will be included with each estimate.
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Responsibilities
Front Desk/Billing Staff: Provide GFEs, track requests, and ensure compliance with required timelines.
Providers: Supply accurate information about services and expected charges.
Compliance Officer: Oversee adherence to the No Surprises Act requirements and maintain documentation.
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Documentation
Copies of all Good Faith Estimates will be retained in the patient’s record for at least six (6) years from the date provided.
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References
No Surprises Act, Section 2799B-6 of the Public Health Service Act
45 CFR §149.610 – Requirements for Good Faith Estimates for Uninsured and Self-Pay Patients
Centers for Medicare & Medicaid Services (CMS) Guidance on Good Faith Estimates
USave Health
Practice/Company Name: USave Health
Primary Business Address: 2630 W Broward Blvd Suite 203-1842, Fort Lauderdale, FL 33312-1314
Phone: 954-870-4790
Email: policy@usavehealth.com
Website: usavehealth.com
Effective Date: [10/1/2025]
Last Updated: [10/1/2025]