Practice desk · Fees and paperwork
Good faith estimates for therapists: what the No Surprises Act requires
If you see clients who pay out of pocket, federal rules have required a written good faith estimate since January 1, 2022. Most therapists know that much. Fewer know the deadlines, the required disclaimers, or what happens when a bill comes in higher. Here is the rule as written, in plain language, with every requirement linked to its source.
- Uninsured clients, and insured clients who don’t want a claim sent to their plan, are “self-pay” under the rule and are entitled to a written good faith estimate.
- Deadlines are short: 1 business day after scheduling if the visit is 3+ business days out, 3 business days if it is 10+ business days out, and 3 business days after a request.
- Any conversation about cost counts as a request for an estimate.
- For ongoing therapy, one estimate can cover recurring sessions for up to 12 months. After that, issue a new one.
- If a bill comes in at least $400 above the estimate, the client can start federal patient-provider dispute resolution. While it is pending you cannot send the bill to collections.
Who counts as self-pay
The regulation, 45 CFR 149.610, defines an uninsured (or self-pay) individual in two ways. [eCFR 149.610] The first is someone with no coverage for the service under a group plan, individual insurance, a federal health program, or the federal employee plan. The second is someone who does have coverage but “does not seek to have a claim” for the service submitted to that plan.
For a typical private-pay therapy practice, that second group is large. It includes clients who have insurance but choose to pay you directly. CMS also notes that the estimate rules apply to people whose only coverage is a health care sharing ministry, short-term limited-duration insurance, a farm bureau plan, or self-funded student coverage. [CMS fact sheet]
The rule puts the burden of asking on you. As the convening provider, you must ask whether the client is enrolled in coverage and, if so, whether they want a claim submitted. [eCFR 149.610(b)(1)] Build both questions into intake so the answer is recorded, not assumed.
If you give clients superbills to submit for out-of-network reimbursement, read the definition closely and decide your policy deliberately. When in doubt, issuing an estimate costs little.
Telling clients they can get one
Before any estimate is issued, you have a notice duty. Information about the availability of good faith estimates must be: [eCFR 149.610(b)(1)(iii)]
- written clearly and prominently displayed on your website, where it is easily searchable from a public search engine;
- posted in your office and where scheduling or cost questions happen;
- given orally when a client schedules or asks about cost; and
- available in accessible formats and in the languages your clients speak.
One line in the rule changes how you should handle fee conversations: you must treat “any discussion or inquiry regarding the potential costs” as a request for a good faith estimate. [eCFR 149.610(b)(1)(iv)] A prospective client who asks “what do you charge?” on a consult call has, for this purpose, requested an estimate.
Deadlines
The timelines depend on when the service is scheduled and whether the client asked. [eCFR 149.610(b)(1)(vi)]
| Situation | Estimate due |
|---|---|
| Service scheduled at least 3 business days ahead | No later than 1 business day after scheduling |
| Service scheduled at least 10 business days ahead | No later than 3 business days after scheduling |
| Client requests an estimate | No later than 3 business days after the request |
If an estimate was given on request and the client then schedules, you issue a new estimate for the scheduled service within the scheduling timelines. [eCFR 149.610(b)(1)(ix)] If the scope changes after scheduling (different fee, frequency, number of sessions, or provider), the client gets a new estimate no later than 1 business day before the service. [eCFR 149.610(b)(1)(vii)]
The estimate must be in writing, on paper or electronically depending on what the client asks for. Electronic estimates must be something the client can save and print. You may explain it by phone, but a verbal estimate alone does not satisfy the rule. [eCFR 149.610(e)]
What it must include
The content list is specific. A good faith estimate for a self-pay client must include: [eCFR 149.610(c)(1)]
- the client’s name and date of birth;
- a plain-language description of the primary service and, if scheduled, the date;
- an itemized list of expected services, grouped by provider;
- applicable diagnosis codes, expected service codes, and expected charges for each item;
- the name, National Provider Identifier, and Tax Identification Number of each provider, plus the state and location where services will be provided;
- a list of services expected to need separate scheduling, with the required disclaimer above it;
- a disclaimer that there may be other recommended services not reflected in the estimate;
- a disclaimer that it is only an estimate and actual items, services, or charges may differ;
- a disclaimer explaining the client’s right to dispute resolution if billed charges are substantially higher, with instructions for starting it, and a statement that using it will not affect the quality of care; and
- a disclaimer that the estimate is not a contract and does not require the client to receive services from you.
Two items catch therapists off guard. One is the diagnosis code, which may not exist yet before a first session; describe the expected service and update the estimate once you have one. The other is the “expected charge,” which the rule defines as your cash-pay rate for self-pay clients, reflecting any discounts you give them. [eCFR 149.610(a)(2)(v)] If you offer a sliding scale, the estimate should show the rate this client will actually pay.
Ongoing therapy: the 12-month rule
Therapy is a recurring service, and the rule allows for that. You can issue a single estimate for recurring sessions if it states the expected scope clearly, such as timeframe, frequency, and total number of sessions. [eCFR 149.610(b)(1)(x)] The scope cannot exceed 12 months. If you expect to keep seeing the client beyond that, you issue a new estimate and explain what changed.
In practice, many clinicians estimate a reasonable episode of care: for example, weekly 53-minute sessions at the client’s rate for a stated number of weeks. Set a calendar reminder before the scope runs out, and revise early if frequency or fee changes.
Estimates you issue are part of the client’s medical record and must be kept that way. Clients can request a copy of any estimate issued in the last 6 years. [eCFR 149.610(f)(1)]
When the bill is higher: dispute resolution
The enforcement mechanism is patient-provider dispute resolution (PPDR). A client can use it if your total billed charges are “substantially in excess” of the estimate, defined as at least $400 more than the total expected charges you listed. [eCFR 149.620] The client must start it within 120 calendar days of receiving the first bill with those charges, and pays an administrative fee. [eCFR 149.620]
An independent dispute resolution entity then decides what the client owes. CMS says you will be asked to provide the estimate, the bill, and documents explaining why the bill is higher. [CMS] While the dispute is pending you may not move the bill to collections or threaten to, must pause collections already underway, cannot charge late fees, and cannot retaliate against the client for using the process. If you and the client settle first, you must notify the dispute entity within 3 days.
The rule also forgives honest mistakes if you correct them as soon as practicable, though a bill that exceeds the estimate by $400 or more can still go to dispute if the error wasn’t fixed before the service. [eCFR 149.610(f)(3)]
A workable setup
- Website notice. Add a short, plain statement about good faith estimates to your fees page.
- Intake questions. Ask about coverage and whether the client wants a claim submitted, and record the answer.
- Template. Build one estimate that includes every required element and disclaimer, so you only change client details, codes, rate, and scope.
- Timing. Send it the same day a new client schedules. That clears every deadline in the table.
- Renewal. Calendar a reissue before the 12-month scope ends or when fee or frequency changes.
- Records. Keep each estimate in the client file.
Some practice-management systems include an estimate form. SimplePractice’s support documentation, for example, describes creating a good faith estimate from the client’s overview page and sharing it through the client portal for signature (as of October 2026; features change, so check the current page). [SimplePractice support] Whatever tool you use, compare its output against the content list above. The legal responsibility stays with you.
For the fee side of private pay, see our guides to superbills, what to set up before taking insurance, and whether to take insurance at all.
Primary sources
Every rule on this page was checked against these official pages on October 24, 2026. Rules and agency guidance change; read the current version before you rely on it.
- 45 CFR 149.610: Requirements for good faith estimates for uninsured (or self-pay) individuals (eCFR, current text)
- 45 CFR 149.620: Patient-provider dispute resolution (eCFR, current text)
- CMS: Key Responsibilities for Health Care Providers and Facilities Under the No Surprises Act (revised January 2025)
- CMS: Providers, payment resolution with patients
- CMS/HHS: Good Faith Estimate and Patient-Provider Dispute Resolution guidance for uninsured or self-pay individuals (December 2021)
Limitations
- This page covers the federal rule for uninsured and self-pay clients. It does not cover the separate No Surprises Act rules for insured clients, such as balance-billing limits and advanced explanations of benefit.
- Some states have their own estimate or billing laws. A state process that falls short of the federal requirements does not satisfy the federal rule.
- Agency guidance and enforcement change. Check the linked sources before relying on any detail here.
- This is education, not legal advice. For questions about your specific practice, consult a health care attorney or your professional association.
Referral link: SimplePractice. Some links are referral links; they don’t cost you anything extra, and we may receive a commission or credit. How referral links work.
Education for clinicians, not medical or legal advice. This page summarizes published research for licensed mental health professionals. It is not a treatment recommendation for any individual, and it does not replace your own clinical judgment, your licensing board’s rules, or consultation with a prescriber or attorney. Evidence reviewed through October 24, 2026. Spot an error? Tell us and we will fix it.
Keep reading