CurrentMedicarePolicy N/A

Guidance on Good Faith Estimates and the Patient-Provider Dispute Resolution (PPDR) Process

Guidance implementing No Surprises Act requirements for providing good faith estimates to uninsured or self-pay individuals and the PPDR process for disputes over billed charges; applies to health care providers and facilities (including air ambulance) furnishing services on or after January 1, 2022.

Policy Summary

PayerMedicare

PolicyGuidance on Good Faith Estimates and the Patient-Provider Dispute Resolution (PPDR) Process

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2022

Next Review DateN/A

Key ActionWhen an uninsured or self-pay individual schedules or requests an item or service, the convening provider/facility must provide a good faith estimate and contact co-providers within 1 business day to request their GFE information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2022-01-01effective date for GFE requirements

3 business daystimeframe to provide GFE after request

6 yearsretain and provide previously issued GFEs

$400PPDR eligibility threshold

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time limit to initiate dispute

Good Faith Estimate and PPDR Criteria

Good Faith Estimate and PPDR criteria

Covered when ALL of the following are met:

ALL of the following

Who is eligible: Uninsured or self-pay individuals (those who do not have certain types of health insurance or who do not plan to use insurance to pay for the item or service).
See definition of uninsured/self-pay and eligibility
Trigger: Provider or facility must provide a good faith estimate when an uninsured or self-pay individual schedules an item or service or when the individual requests an estimate (regardless of scheduling).
Applies to items/services scheduled or requested on or after January 1, 2022.
Timing: Convening provider/facility must provide the good faith estimate to the individual; when convening provider receives scheduling or request they must contact co-providers/co-facilities to obtain reasonable expected charges for items/services to be included in the GFE.
Contact and timing requirements (see policy for specific business-day timelines).
Content: The good faith estimate must include patient name and date of birth; clear description of the primary item or service (and scheduled date if applicable); an itemized list of items or services grouped by provider or facility; applicable diagnosis codes; expected service codes; expected charges; name, NPI, and TIN of each provider or facility; and state and office/facility locations. It must also include required disclaimers (PPDR rights, that the GFE is not a contract, and notices about separately scheduled items/services).
Include list of separately scheduled items with the required disclaimer language.
Format & retention: The GFE must be provided in a written form (paper or electronic). If electronic, it must be in a savable/printable format. The GFE must be maintained in the individual's medical record, and copies of previously issued GFEs must be retained and provided upon request for up to 6 years.
Retention and accessibility requirements apply.
Co-provider responsibilities: Co-providers/co-facilities identified in the GFE must submit their expected charge information to the convening provider/facility when requested, and replacement co-providers less than 1 business day before service may be treated as eligible for dispute if billed charges exceed the original expected charge threshold.
See policy for 1 business-day replacement rules and enforcement discretion periods.
Notice of PPDR: The GFE must include a disclaimer informing the individual of the right to initiate the Patient-Provider Dispute Resolution (PPDR) process if billed charges are substantially in excess of the expected charges and provide instructions on how to initiate the PPDR process; include a statement that initiating PPDR will not adversely affect care quality.
Required PPDR disclaimer text and instructions must be included in the GFE.

PPDR Eligibility and Process Criteria

Criteria for an item or service to be eligible for the PPDR process:

ALL of the following

Eligibility threshold per provider/facility: For each unique provider or facility listed on the good faith estimate, the total billed charges for that provider or facility must exceed the total expected charges included in the GFE by $400 or more to be eligible for PPDR.
The $400 threshold is applied separately for each provider or facility listed on the GFE.
Aggregation: To determine eligibility for a specific provider/facility, add together the total expected charges for that provider/facility from the GFE and compare to the total billed charges for that provider/facility (including billed items not listed on the GFE).
Billed items not on the GFE are included in the total billed charges for comparison.
Replacement co-provider rule: If a co-provider or co-facility listed in the GFE is replaced by a different co-provider/co-facility less than 1 business day before the scheduled item or service, billed charges by the replacement provider/facility are eligible for PPDR if they exceed the total expected charges for the original co-provider/co-facility by $400 or more; if a timely replacement GFE is provided by the replacement provider/facility, eligibility is determined using that replacement GFE.

Required Codes, Examples, and Thresholds

Required code sets on GFEmixed

ICD-10	Applicable diagnosis codes required on GFE
CPT/HCPCS/DRG/NDC	Expected service codes required on GFE

Estimate Example Codesmixed

ICD	Diagnosis code placeholders shown in estimate examples
Service Code	Service code placeholders (service code type/number) shown in estimate examples

Independent database median paymentmixed

Median payment amount from independent database for same or similar service/provider/geographic area as comparison value

inv-07: PPDR eligibility threshold — $400 per provider/facility

Threshold amount$400 per provider or facility

ApplicationApplied separately to billed charges for each provider or facility listed on the GFE

Replacement co-provider ruleIf a replacement co-provider/facility furnishes the service <1 business day before scheduled service, eligibility compares billed charge to the original co-provider's expected charge using the $400 rule

inv-08: Determination thresholds — billed vs expected charge rules and credible justification guidance

Billed ≤ expected chargeIf the billed charge is equal to or less than the expected charge on the GFE, the case is ineligible for PPDR

Provider and Facility Responsibilities

Documentation Required

Recordkeeping and Applicability

A good faith estimate (GFE) issued to an uninsured (or self-pay) individual is part of the patient's medical record and must be retained in the same manner as other medical record documents. Convening providers and convening facilities must provide a copy of any previously issued GFE furnished within the last 6 years to the uninsured (or self-pay) individual upon request. Providers and facilities that follow state GFE processes that do not meet federal requirements will be considered noncompliant with federal GFE requirements. Providers or facilities that, despite acting in good faith and with reasonable diligence, make an error or omission in a required GFE will not be deemed noncompliant solely for that error if they correct the information as soon as practicable. If items or services are furnished before an error in a GFE is corrected and the actual billed charges are substantially in excess of the GFE, the provider or facility may be subject to the PPDR process. When compliance requires reliance on information from another entity or individual, a provider or facility will not be treated as noncompliant if it reasonably relied in good faith on that information, unless the provider or facility knew or should have known the information was incomplete or inaccurate. Upon learning the information is incomplete or inaccurate, the provider or facility must provide corrected information to the uninsured (or self-pay) individual as soon as practicable.

Key Terms and Definitions

inv-16: Convening provider/facility — the provider or facility responsible for scheduling or receiving GFE requests

DefinitionThe provider or facility who schedules an item or service or receives the initial request for a good faith estimate and is responsible for providing the GFE and coordinating co-provider information

ResponsibilityMust provide the GFE to the uninsured/self-pay individual and include items reasonably expected to be provided by co-providers/co-facilities

Role in PPDRServes as the primary listed provider/facility for eligibility and billed-versus-expected charge comparisons under PPDR

inv-17: Co-provider/co-facility — provider or facility furnishing items/services in conjunction with the convening provider

DefinitionA provider or facility, other than the convening provider/facility, that furnishes items or services customarily provided in conjunction with the primary item or service

Policy Summary

PayerMedicare

PolicyGuidance on Good Faith Estimates and the Patient-Provider Dispute Resolution (PPDR) Process

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2022

Next Review DateN/A

SourceLink

On This Page

See policy for timing and replacement GFE conditions.

Initiation timing: The initiation notice to begin PPDR must be submitted within the timeframe specified in the policy (from the date on the original bill).

Refer to policy for the specific initiation window and administrative fee requirements.

Substantially in excess without credible justificationIf billed charge substantially exceeds the GFE and provider fails to provide credible information, the amount to be paid = the GFE amount (or $0 for items not on the GFE)

Credible justification providedIf provider provides credible information, payment = lesser of billed charge or median payment from an independent database, but not less than the expected GFE amount

Aggregation and fee adjustmentSDR entity sums determinations for each item and reduces final amount by the administrative fee paid by the individual if final amount is lower than billed charge

Denial Risk

Collections and Retaliation Prohibition

While a Patient Provider Dispute Resolution (PPDR) process is pending, the provider or facility must not move the disputed bill into collections or threaten to do so. If the bill has already been placed in collections, the provider or facility should cease collection efforts. The provider or facility must suspend accrual of any late fees on unpaid amounts relating to the disputed item or service until after the PPDR process concludes. Providers and facilities must not take or threaten any retributive action against an uninsured (or self-pay) individual for initiating or using the PPDR process.

Note

Submission via Federal IDR Portal

When practicable, providers and facilities should use the online federal IDR portal to submit documentation and receive notices for the PPDR process. The federal IDR portal is the same portal used for other federal IDR processes. Providers and facilities may receive notices from HHS and the Selected Dispute Resolution (SDR) entity, submit additional supporting documents, and receive determinations via the portal or by email. HHS strongly recommends submission through the federal IDR portal when the SDR entity requests information.

Portal is preferred for submissions, notices, and determinations
Providers may also receive communications by email, electronic or paper mail, or phone

Documentation Required

Provider submission requirements

If the SDR entity determines an initiation notice is eligible, it will notify the provider or facility and require certain documentation within 10 business days. Providers and facilities should submit the requested information to the SDR entity (preferably via the federal IDR portal) within that 10-business-day period. The required documentation includes: (1) a copy of the GFE provided to the uninsured (or self-pay) individual for the disputed items or services (readable photocopy or electronic image is acceptable); (2) a copy of the billed charges provided to the uninsured (or self-pay) individual for the disputed items or services (readable photocopy or electronic image is acceptable); and (3) if available, documentation evidencing that the difference between the billed charges and the expected charges in the GFE reflects costs of a medically necessary item or service and is based on unforeseen circumstances that could not reasonably have been anticipated when the GFE was provided. The SDR entity will review all timely submissions and make a determination no later than 30 business days after receiving the information.

Copy of the GFE for the items/services under dispute
Copy of the billed charges for the items/services under dispute
Documentation, if available, showing the charge difference is due to medically necessary, unforeseen circumstances

Prior Authorization

Initiation and eligibility

Eligibility and initiation: An uninsured (or self-pay) individual must submit an initiation notice to HHS within 120 calendar days from when they received the initial bill for the items or services. After HHS selects and notifies the SDR entity, the uninsured (or self-pay) individual must pay the required administrative fee to begin the PPDR process. The SDR entity will review the initiation notice for eligibility and completeness; if eligible and complete, the SDR entity will notify the parties that the item or service is under review and will require the provider or facility to submit the documentation described above within 10 business days. If information is missing to determine eligibility, the uninsured (or self-pay) individual has 21 calendar days to provide additional information after notification of the deficiency. Parties may request extensions for extenuating circumstances.

Initiation notice must be sent within 120 calendar days of the initial bill
Uninsured (or self-pay) individual pays administrative fee after SDR selection
Provider/facility must supply required documentation within 10 business days of SDR notice
Patient has 21 calendar days to cure any information deficiencies

ExamplesLabs, tests, anesthesia, or other services typically used during a scheduled procedure that may be listed separately on the GFE

ObligationMust supply expected charge information to the convening provider within required timeframes when requested

inv-18: Good faith estimate (GFE) — itemized expected charges for scheduled or requested services

DefinitionAn itemized notification of expected charges for scheduled or requested items and services provided to uninsured or self-pay individuals

Content requirementsMust include patient name/DOB, description of primary item/service, itemized list grouped by provider/facility, diagnosis and expected service codes, expected charges, provider names/NPIs/TINs/locations, and required disclaimers

Delivery and retentionProvided when scheduled or upon request; must be written (paper or electronic), savable/printable if electronic, and retained/producible for up to 6 years

inv-19: Patient-Provider Dispute Resolution (PPDR) — process for independent determination via HHS-certified SDR entity

DefinitionProcess allowing uninsured or self-pay individuals (or their authorized representative) to seek an independent determination from an HHS‑certified Selected Dispute Resolution (SDR) entity when billed charges are substantially in excess of the GFE

Initiation windowUninsured/self-pay individuals must submit an initiation notice within 120 calendar days of the date on the original bill to start PPDR

Administrative feeA fee (established at $25 in 2022) is paid by the individual to the SDR entity to initiate PPDR; adjustments applied to final determination when appropriate

inv-20: Authorized representative — individual authorized under State law to act for the uninsured/self-pay individual

DefinitionAn individual authorized under State law to act on behalf of the uninsured or self-pay individual; not affiliated with the provider/facility or an employee represented in the GFE unless a family member

Role in PPDRMay initiate PPDR, submit required documentation, and receive determinations on behalf of the individual

Eligibility constraintMust meet State law requirements and cannot be a provider or facility employee represented in the GFE unless they are a family member

inv-21: Patient-Provider Dispute Resolution — brief restatement of PPDR process for disputing substantially in excess charges

Short process summaryUninsured/self-pay individuals billed substantially in excess of a GFE may initiate PPDR to seek an independent SDR determination of the amount they must pay

Who decidesAn HHS‑certified Selected Dispute Resolution (SDR) entity reviews documentation from both parties and makes a binding determination

Provider obligations during PPDRProviders must submit GFEs, billed charges, and justification documentation to the SDR entity and must not send disputed bills to collections while PPDR is pending

inv-22: credible information — definition used to justify differences between bill and GFE

DefinitionInformation that, upon critical analysis, is worthy of belief and trustworthy for justifying differences between billed charges and expected charges on the GFE

PurposeUsed by the SDR entity to determine whether higher billed charges reflect costs of medically necessary care due to unforeseen circumstances

AssessmentCredibility is evaluated by the SDR entity based on documentation timely submitted by the provider or facility

inv-23: independent database / median payment amount — definition of the independent database used for median payment comparisons

DefinitionAn independent database as defined in §149.140(a)(3) used to identify the median payment amount paid by plans or issuers for the same or similar service by similar providers in the geographic area

Use in determinationsWhen credible justification is provided, the SDR entity may select the median payment amount from the independent database as the payment amount (subject to compare with billed charge and GFE)

Floor ruleIf the independent database median payment is less than the expected GFE amount, the amount to be paid equals the expected GFE amount