Good Faith Estimates: What Private Practices Must Give Clients

Who Counts as Uninsured or Self Pay Under the Rule

The No Surprises Act puts new requirements on providers, but not every client is covered in the same way. The law applies to most clients who are not using insurance for payment. This means any adult or child who pays your full fee, receives a sliding scale, or otherwise does not ask you to bill their health plan for part or all of the session cost. In practice, many therapists see a mix of insured and self pay clients.

Some clients may have insurance but choose not to use it. Maybe their plan does not cover mental health, or they want more privacy. For these clients, you are still required to provide a written good faith estimate. The same is true for those with no health insurance at all. The law does not distinguish between people who never had coverage and those who opt out for certain providers.

There are a few exceptions. If a client is using out of network benefits and you are submitting claims on their behalf, the estimate rule does not apply. It also does not cover emergency situations, though these are rare in typical private practice therapy. Outpatient mental health is almost always a scheduled, non-urgent service where the estimate requirement is triggered.

Keep reading: One Out of Network Claim, Traced From Session to Check

The Required Elements of a Written Good Faith Estimate

Federal rules set out a list of items that must appear in every good faith estimate. These are not optional. At minimum, your estimate needs to include:

• The client's full legal name, date of birth, and contact information
• Your name, credentials, practice name, and office contact details
• A clear description of each service you expect to provide
• The CPT code for each service (such as 90837 for a 60-minute session)
• Your fee for each service
• How often you expect to provide each service, and the total projected cost
• The date the estimate is created
• A statement about the client's right to dispute charges above the estimate
• Instructions for how the client can start a dispute process

The estimate should be detailed enough for the client to understand what to expect. Vague descriptions like "therapy session" do not meet the standard. If you offer both individual and family sessions, list each with separate CPT codes and fees. If you sometimes charge for late cancels or missed appointments, note whether these are included or not.

Diagnosis codes may be included when applicable, but this can raise sensitive issues. Many providers prefer to list the most likely diagnosis or use "no diagnosis" for the initial estimate, updating as more is known. The rules do not force you to give a diagnosis before you have met the client, but you do need to use the fields as accurately as possible.

Timing: The One and Three Business Day Windows

Delivery windows for good faith estimates are not flexible. The law requires you to send a written estimate to a self pay or uninsured client:

• Within one business day after scheduling if the appointment is booked three or more business days in advance
• Within three business days after scheduling if the appointment is booked at least ten business days in advance

For example, if a new client calls on a Monday to schedule a session for Wednesday, you must provide the estimate by Tuesday. If they call on Monday to schedule for next Friday, you have until Thursday to deliver the estimate. The clock starts as soon as the appointment is confirmed, not when you gather all intake paperwork.

If you offer standing weekly appointments, the timing rules mean you provide one estimate covering the expected course of care, not a new one each week. However, if a client reschedules or returns after a long gap, you must treat the new booking as a separate event and deliver a fresh estimate if required by the timing.

These rules apply even if the client is returning to your practice after a break. Every scheduled episode of care starts the timing window again, unless you have already provided a valid estimate that covers ongoing sessions.

Keep reading: How Parity Rule Changes Are Reshaping Out of Network Practice

Estimating a Course of Care for Recurring Weekly Sessions

The most common scenario in private practice is a client attending weekly therapy for an extended period. The rule expects you to estimate the "expected course of care." This means forecasting the number and type of sessions you believe will be needed, even if the actual course is uncertain.

Most practices use a standard range for recurring therapy: for example, "52 weekly sessions of 60 minutes each" over the next 12 months. If you expect to see a client for less frequent sessions, such as biweekly or monthly, specify the number, duration, and frequency. If you offer both psychotherapy and occasional family sessions, include both lines with CPT codes and fees.

It is understood that the actual number of sessions may change based on progress or client needs. The estimate is not a contract for a fixed number of visits, but it must be realistic based on your clinical judgment and typical course of care for the presenting problem. If a client is likely to need extra services like psychological testing, add those with the relevant codes and fees.

What If Frequency Changes?

If the client's therapy frequency changes, such as moving from weekly to monthly, you are expected to update the estimate. This is part of your ongoing compliance. Many practices revisit the estimate at the client's request, at a periodic review, or when recommending a change in care plan.

Including Sliding Scale and Cancellation Fees

If a client is on a sliding scale, use the fee you expect to charge. If your fee varies, explain this in a note within the estimate. Some providers write, "Fee for each session will be between $X and $Y, based on documented income." Estimates do not need to list cancellation fees unless you regularly charge them and expect the client to incur these costs. If you do, include a statement such as, "Missed session fee of $40 may apply in accordance with office policy."

The Dispute Resolution Threshold and How the Process Works

The No Surprises Act includes a process for clients to dispute charges that are "substantially in excess" of the good faith estimate. The threshold is set at $400 above the total expected costs for the provider or facility listed on the estimate. If the client receives a bill that is $400 or more above the estimated total, they can initiate a dispute through a formal process.

Clients start the dispute by submitting an application to a federal arbitration system, not to your practice directly. You will be notified and given a chance to respond, explaining why the charges exceeded the estimate. You may need to show documentation of changes in the plan, extra services requested by the client, or other reasons for the difference.

Possible Outcomes

The arbiter will review both sides. If the overage is found to be reasonable, such as for extra sessions requested by the client, or a change in diagnosis that required more complex care, the provider's charges may stand. If not, the client may be entitled to a reduction. The process is designed to be accessible, but most routine therapy overages will not reach the dispute stage unless there is a major error in the estimate or a breakdown in communication.

It is good practice to alert the client if you see that the current course of care will exceed the original estimate by a significant margin. Update the estimate as soon as you anticipate a change, not after the fact.

See how SuperbillDesk handles this for mental health

Required Notice, Plain Language, and Accessibility

The rules do not just require that you give an estimate, they also specify how you communicate it. Every provider must post a notice about the right to receive a good faith estimate. This notice needs to be visible in your office and on your website, in a way that clients see it before or when they first make an appointment.

The language of both the notice and the estimate itself must be clear and plain. Avoid medical or legal jargon. Federal guidelines recommend that you write at a level most adults can understand, ideally at or below an eighth-grade reading level.

Alternate Formats and Language Access

If you have clients who need materials in other languages or alternative formats, such as large print or audio, be prepared to provide the estimate in a way they can use. This is especially important if you regularly serve clients with disabilities or who speak languages other than English. The law does not force you to translate into every language, but you must make a reasonable effort for your client base.

Always keep a copy of your posted notice and your standard template. This shows you are making a good faith effort to comply, even if a particular client does not request a written estimate.

Recordkeeping and Reissuing the Estimate When Fees Change

Providers must keep a copy of every good faith estimate they send. This record should include the date sent, the recipient, and the details of the estimate itself. Most practices store these with other client documentation, either in the electronic health record or in a secure, organized file. Retain these records for at least six years, which matches other federal and state retention rules for client records in most states.

If your fees change, for example, you implement an annual increase or add new services, you are required to issue a new estimate to affected clients. This should happen before the new fee takes effect whenever possible. Send the updated estimate using the same method as before, and note the reason for the change. If the client's course of care changes, such as adding group therapy or psychological testing, update the estimate to include the new codes and fees.

Some practices set a routine annual review for all estimates, issuing updates at the start of each new calendar year. Others update only as needed, but always before a change in the costs or services provided. Make sure your process is consistent, documented, and easy to follow in an audit.

Automating superbill and estimate generation can help ensure your CPT codes, fees, and client information are always up to date. Tools designed for mental health billing, such as those that generate monthly superbills with correct fields and client delivery, can help you stay compliant and reduce administrative burdens.