CurrentMedicarePolicy N/A

FAQs: Good Faith Estimates (GFEs) for Uninsured or Self-Pay Individuals — Enforcement Discretion and Interoperability Guidance

FAQs clarifying HHS/CMS guidance on Good Faith Estimates for uninsured/self-pay individuals, extending enforcement discretion for inclusion of co-provider/co-facility charges and encouraging adoption of standards-based APIs (e.g., HL7 FHIR) for interoperability.

Policy Summary

PayerMedicare

PolicyGood Faith Estimates (GFEs) for Uninsured or Self-Pay Individuals — Enforcement discretion and interoperability guidance

Policy CodePolicy N/A

Change TypeGuidance/Clarification

Effective DateDec 2, 2022

Next Review DateN/A

Key ActionHHS is extending enforcement discretion for GFEs that do not include expected charges from co-providers or co-facilities and encourages states to adopt a similar approach while discretion is exercised.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jan 1, 2023Enforcement start originally expected

Jan 1, 2022–Dec 31, 2022Prior discretion period

Oct 7, 2021IFR published

FHIR / HL7Recommended standard

Good Faith Estimate (GFE) Enforcement and Interoperability Expectations

GFE coprovider/co-facility cost inclusion enforcement and interoperability guidance

Enforcement stance and interoperability expectations for inclusion of co-provider and co-facility charges in Good Faith Estimates (GFEs).

HHS is extending enforcement discretion, pending future rulemaking, for situations where GFEs for uninsured (or self-pay) individuals do not include expected charges from co-providers or co-facilities; HHS will not enforce the January 1, 2023 applicability date for this requirement.

HHS previously exercised enforcement discretion for GFEs provided from January 1, 2022 through December 31, 2022 to allow time for development of mechanisms for convening providers/facilities and co-providers/co-facilities to exchange complete and accurate pricing information.

HHS received stakeholder feedback that compliance by January 1, 2023 is unlikely due to technical and business practice complexities involved in exchanging GFE data.

HHS encourages adoption of standards-based APIs (for example, HL7 FHIR) to enable industry-wide interoperability for transmission of GFE data between convening providers/facilities and co-providers/co-facilities and will support development of such standards.

Policy Summary

PayerMedicare

PolicyGood Faith Estimates (GFEs) for Uninsured or Self-Pay Individuals — Enforcement discretion and interoperability guidance

Policy CodePolicy N/A

Change TypeGuidance/Clarification

Effective DateDec 2, 2022

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Operational Guidance and Enforcement Discretion for Providers and Facilities

Prior Authorization

Enforcement discretion: coprovider/co‑facility charges excluded from GFEs

HHS is exercising enforcement discretion (i.e., will not enforce beginning January 1, 2023) for situations where a Good Faith Estimate (GFE) for an uninsured or self-pay individual does not include expected charges from co‑providers or co‑facilities, and encourages states to take a similar approach while this discretion is in effect.

This discretion was previously exercised for GFEs provided January 1, 2022 through December 31, 2022 and is extended pending future rulemaking.
HHS expects industry adoption of standards-based APIs (e.g., HL7 FHIR) to enable interoperable exchange of GFE data and that any future rulemaking will include a prospective applicability date to allow time for compliance.

Key Terms

Good Faith Estimate (GFE) — definition and required elements

Statutory basisGFE required by PHS Act section 2799B-6 and implementing regulations at 45 CFR 149.610.

Required contentA Good Faith Estimate must include expected charges for any item or service reasonably expected to be provided in conjunction with the scheduled or requested service, including those from co‑providers and co‑facilities (45 CFR 149.610(b)(1)(v) and (2)(i)).

PurposeProvides uninsured (or self‑pay) individuals an itemized estimate of expected charges for scheduled or requested items or services and associated co‑provider/co‑facility charges.

Regulatory contextInterim final rules (Requirements Related to Surprise Billing; Part II) published October 7, 2021 implement the GFE requirements and explain enforcement approach.

Enforcement noteHHS has exercised and extended enforcement discretion regarding inclusion of co‑provider/co‑facility charges while technical and interoperability solutions are developed.

FHIR / HL7 — interoperability approach

Standards referencedHealth Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) is identified by HHS as holding potential to support interoperability for GFE data exchange.

RoleFHIR/HL7 is recommended as a standards‑based API approach to enable transmission of GFE data between convening providers/facilities and co‑providers/co‑facilities.

Strategy alignmentAdopting API‑based standards for GFE exchange is part of HHS's broader strategy to promote bi‑directional data exchange and industry interoperability.

Implementation expectationHHS encourages market‑wide adoption of standards‑based APIs to achieve industry‑wide interoperability and facilitate automation of comprehensive GFEs.