This article covers the rule at 45 CFR 149.610, the dispute process at 45 CFR 149.620, and two Oregon points. It is general information, not legal advice.
Who must give one, and to whom
The rule covers any provider acting within the scope of a state license or certification, plus licensed facilities. CMS's first GFE FAQ says no specialty, facility type, or site of service is exempt. That includes counselors, social workers, prescribers, and licensed SUD programs.
A client is uninsured or self-pay if they have no group, individual, federal program, or FEHB coverage, or if they have employer, individual, or FEHB coverage but do not want a claim submitted. CMS's December 2024 FAQ adds that members of health care sharing ministries and people with only short-term limited-duration plans count as uninsured.
OHP and Medicare members are a different case. The same FAQ says providers generally do not owe GFEs to people in Medicare, Medicaid, or other federal programs.
Staff must ask whether the person has coverage and whether they want a claim filed. If a licensed clinician supervises an unlicensed student, the GFE is the licensed provider's job and carries that provider's name, NPI, and TIN.
The notice requirement
People must be told they can get an estimate. The notice goes on your website where search engines can find it, in the office, and wherever scheduling or cost questions happen. Staff must also say it out loud when scheduling or when someone asks about cost. It must be available in accessible formats and in the languages your clients speak. Any conversation about cost counts as a request. CMS publishes a model notice.
A request to anyone who handles scheduling, billing, or patient care is generally valid, and that person must pass it on in time.
Deadlines
- Scheduled 3 to 9 business days out: GFE due within 1 business day of scheduling.
- Scheduled 10 or more business days out: due within 3 business days.
- Requested without scheduling: due within 3 business days of the request.
- Scheduled fewer than 3 business days out: not required, per CMS's second FAQ. A voluntary GFE in that window is not eligible for the dispute process.
Business days are Monday through Friday, minus federal holidays, and the GFE is due by 11:59 PM. It must be written, on paper or electronically as the client prefers, in a form they can save and print. If the expected charges, frequency, services, or providers change, a new GFE is due at least 1 business day before the service.
Ongoing therapy and the 12-month limit
You may issue one GFE for recurring services, and CMS names periodic counseling as an example. It must state the timeframe, frequency, and total number of sessions. It cannot cover more than 12 months. After that, issue a new one and explain what changed.
A form that lists only a per-session fee does not meet this rule, because it gives no frequency or total. Underestimating also creates risk. If a GFE shows 12 sessions at $150 ($1,800) and the client attends 20 ($3,000), billed charges run $1,200 over the estimate.
What has to be on it
- Client name and date of birth
- A plain-language description of the primary service, with the date if scheduled
- An itemized list of expected services, grouped by provider or facility
- Diagnosis codes, service codes, and the expected charge for each service
- Name, NPI, and TIN for each provider or facility, and where services will happen
- Services that need separate scheduling, under the required disclaimer
- Disclaimers that it is only an estimate, that more services may be recommended, that it is not a contract, and that the client may dispute a bill, with instructions and a statement that disputing will not affect their care
The expected charge is your cash rate after any self-pay discount. Diagnosis codes are needed only when the charge depends on them, so an intake GFE before an assessment can leave them off, but service codes and charges still go on. CMS's fourth FAQ explains how sliding-fee providers can comply. The CMS model GFE lays out the required elements.
Co-providers and where enforcement stands
On paper, the convening provider, meaning the one scheduling the primary service, must gather co-provider estimates within 1 business day and include them. In behavioral health that could be an outside lab or a separate prescriber. HHS has not enforced that piece. Its December 2022 FAQ extended enforcement discretion pending future rulemaking and promised a prospective compliance date.
As of October 2026, no such rule has been published. A June 2026 Federal Register notice renewed the GFE information collection without change. You still must estimate your own charges. If a client schedules directly with the other provider, that provider owes its own GFE.
Disputes and the $400 line
A client can start patient-provider dispute resolution if a provider's total billed charges are at least $400 more than that provider's expected charges on the GFE. Per CMS, they have 120 calendar days from the initial bill and pay a $25 fee.
While it is open, you may not send the bill to collections or threaten to, and you must pause collection efforts and late fees. Retaliation is prohibited. You have 10 business days after the dispute entity's notice to send the GFE, the bill, and any proof the extra charges were medically necessary and unforeseen.
Records
A GFE is part of the medical record and must be kept like one. Clients can ask for a copy of any GFE issued in the past 6 years.
Two Oregon points
ORS 743B.287 bars out-of-network providers, with some exceptions, from balance billing plan members for services at in-network facilities. It protects insured people and does not replace the federal estimate rule. Section 149.610 says an estimate issued under a state process that falls short of the federal rule does not comply. DFR's 2022 bulletin restated the federal GFE duty and directed complaints about providers to HHS.
ORS 743B.277, added in 2025, requires insurers other than HMOs to credit what a member pays a provider directly toward their deductible and annual out-of-pocket costs. The service must be covered and medically necessary, no claim is submitted, and the amount must be below the average in-network rate for the same license. Clients seeking that credit need documentation, so give them itemized receipts that use the same codes as the GFE.
Checklist
- Post the right-to-estimate notice online, in the office, and at scheduling.
- Add two scheduling questions: what coverage do you have, and do you want us to bill it? Record the answers.
- Use a form with every required element, such as the CMS model.
- For ongoing therapy, state frequency, period, and total sessions, up to 12 months, and set a reissue reminder.
- Reissue when your fee, frequency, service, or clinician changes.
- Each month, compare self-pay billed totals with the GFE and reissue before the gap nears $400.
- Keep GFEs in the chart and be able to produce 6 years of them.
- Write a dispute procedure that pauses collections and late fees.
Easton Hallock is Managing Partner of Saint Health Group, which helps behavioral health and addiction treatment organizations with licensing, compliance, payer contracting, revenue cycle operations, and behavioral health billing.
