Confirm you got a GFE
You need a written Good Faith Estimate from the provider or facility for the care in question.
Good Faith Estimate
Bill $400+ over your Good Faith Estimate? Check the dispute path.
Self-pay and uninsured patients may qualify for the CMS dispute process when a final bill is at least $400 above the Good Faith Estimate. Start by checking the documents and deadline.
What the GFE is
A binding-ish estimate.
If you're self-pay or uninsured (no insurance OR you're choosing not to use insurance), providers and facilities generally must give you a written Good Faith Estimate before scheduled care.
If your final bill is at least $400 more than the GFE, you may qualify for the CMS Patient-Provider Dispute Resolution (PPDR) process. A neutral Selected Dispute Resolution (SDR) entity reviews the case and determines the appropriate payment.
CMS says the dispute needs an initial bill dated within the last 120 calendar days, a copy of the GFE, a copy of the bill, and a $25 administrative fee.
Filing the dispute
Six steps. Keep the documents together.
Confirm the math
CMS uses an at least $400 difference between one provider or facility's final bill and that provider or facility's GFE.
Check the bill date
CMS says the initial bill must be dated within the last 120 calendar days.
Prepare the fee
CMS lists a $25 administrative fee to start the dispute process.
SDR reviews
An independent dispute resolver looks at the GFE, final bill, and provider explanation.
Keep billing records
If billing or collections activity continues during the dispute, save the notices and contact the No Surprises Help Desk.
FAQ
Common questions.
Do I have to be uninsured to use this?
Self-pay (chose not to use insurance) counts too. You don't have to be uninsured. The key is that you didn't run the bill through insurance.
What if my insurer denied the claim and now I'm on the hook?
That's a different process. The CMS GFE dispute path is for bills where you didn't have or didn't use insurance to pay for the care. A denied insurance claim usually starts with the plan's appeal process.
What happens to the $25 fee?
CMS lists a $25 administrative fee. If the dispute is decided in your favor, CMS says the $25 is deducted from the amount you owe the provider.
What evidence helps?
The original GFE document, the final bill, any communication from the provider explaining the increase, and the medical record showing what services were actually performed.
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