Good Faith Estimate Form

The No Surprises Act (NSA) establishes new federal protections against surprise medical bills that take effect in January 2022. The No Surprises Act includes a provision that requires that a Good Faith Estimate (GFE) be provided to any client presenting either with no insurance or choosing not to bill insurance for the visit.

The Centers for Medicare & Medicaid Services (CMS) has clarified that this provision applies to all providers in all settings - however, we suggest that you review the latest CMS information, as well as any statements by your professional organization.

We recommend asking each client whether they have insurance and intend to use it to cover the services that they seek. If the answer to either question is NO, they’ll need a Good Faith Estimate prior to their appointment.

This article walks through the information included in the Good Faith Estimate form available to you within Healthie - as well as how to complete the form, and have your client e-sign. This article and included forms/resources are not intended as legal advice.

The Good Faith Estimate form can be shared to your Healthie provider account - please send a request to hello@gethealthie.com

Which providers & facilities are required to provide GFEs to uninsured (or self-pay) individuals?

Generally, all providers and facilities that schedule items or services for an uninsured (or self-pay) individual or receive a request for a GFE from an uninsured (or self-pay) individual must provide such individual with a GFE. No specific specialties, facility types, or sites of service are exempt from this requirement.

The terms "health care provider (provider)" and "health care facility (facility)" are defined in regulations for purposes of the GFE requirements for uninsured (or self-pay) individuals as:

"Health care provider (provider)" means a physician or other health care provider who is acting within the scope of practice of that provider's license or certification under applicable State law, including a provider of air ambulance services.

Details of the Good Faith Estimate Form

Included in the Good Faith Estimate Form:

Provider Name, NPI, and TIN of all service providers and the state where the services will be rendered
Client name and date of birth
Clear description of service and date scheduled (if applicable)
List of all items and services (including those to be provided by co-providers)
CPT code, diagnosis code, and charge per item of service
List of items from other providers that will require separate scheduling
Disclaimer that separate GFEs will be issued upon request for services listed in number 6, and that items in number 4 will be provided in those separate GFEs
Disclaimer that there may be other services required that must be scheduled separately during the course of treatment and are not included in the GFE
Disclaimer that this is only an estimate and actual services, and charges may differ
Disclaimer informing the client of their rights to a client-provider dispute resolution process if actual billed charges are substantially above the estimate, as well as where to find information on how to start the dispute process
Disclaimer that GFE is not a contract, and the client is not required to obtain services from the provider

Access & Modify the Good Faith Estimate Form

You can request the Good Faith Estimate Form be shared with your Healthie provider account by emailing hello@gethealthie.com

The form will be shared with your account and can be edited for your business.

Please note any text that is highlighted in blue, as it indicates you should add your own personal business information (ie. business name).

Click EDIT in any field box to modify the text/form. Click SAVE when you're done.

You can Preview a copy of your form, or generate a PDF a version by clicking the "Options" button on the top-right of the form

Healthie Workflows for Using the GFE

This Healthie form functions differently than any other templated form, in the respect that there is a portion that needs to be filled out by a provider, but client's need to date & sign it BEFORE their consultation. The Healthie Product Team is looking into ways to make this form-sharing workflow as seamless as possible for both providers & clients.

In the interim, here are some workflow suggestions for you:

1. Have the form automatically send as part of an intake flow, tied to a client group
2. Have the form automatically send after a specific appointment type is booked - there is copy in the form asking the client to not sign the form until it is completed by their provider (and most of the form fields says "To be completed by Office")
3. Convert the form to a charting note (instructions here) which will allow you to complete the form, then upload it to your client's documents for them to sign and re-upload.

More details on these workflows can be found in the sections below.

Filling Out the GFE Form as an Intake Form

To get started, you'll need to share the form with your client, for the form to be associate with their client account.

You can do this by going to Forms > Form Builder > Locate Form > Actions tab (three dots) > Request Form Completion

You'll be able to select your client(s) and/or groups and an instance of the form will automatically be shared with their client account.

Note: Requesting the form multiple times will create multiple instances of the form in their account. You can always return to your forms library and request the form again at the time new Services need to be provided.

Once you've requested the form, an instance of it will be saved within your client's account.

You can now go to their Client Profile > Charting > View Completed Forms > Locate GFE form > Fill Out

The following sections need to be completed by the healthcare provider (To Be Completed by Office sections)

Patient Name & Date of birth (once you share this form with a client's account, it will automatically populate with the patient name and date of birth on file. If this information was NOT on file at the time the form was shared, it will need to be manually entered).
Seeking Services For (what your client is seeking your services for)
Estimated Cost for Services (including CPT codes, diagnosis/procedure code, cost)
Total Estimated Charges
Other Services (items and services that may need to be scheduled by co-providers at your business)

Your client is only responsible to review, date, and sign the form.

Have Client Date & Sign the GFE Form as an Intake Form

Once you've completed the necessary "Office" information, you can notify your client that they can date & sign the form.

Clients will receive an email prompting them to complete a form, with a link to log into their Healthie Client Portal. The form will be completed electronically, and automatically will save within their Healthie account.

You can send this article to your client with step-by-step instruction on how to complete a form.

https://clienthelp.gethealthie.com/article/240-completing-intake-forms

To view the completed form, simply return to View Client's Profile > Charting > View Client Forms > Locate the Good Faith Estimate Form

You'll see a "Completed" status next to the form, with the option to "View"

Click the actions tab (three dots) to delete the requested form, or to save as a PDF.

Convert the GFE to a Charting Form (Optional)

In lieu of the GFE sending to a client as an Intake Form, it may work better for your workflows to use it as a Charting Form. This will keep the form private (only for the provider to see) so you can populate the relevant information. Once completed, you can share the form as a PDF directly with your client, for them to download, sign, and re-upload to their Documents.

1. Convert the GFE to a Chart Note

When you have the form open, click the OPTIONS > Convert to Charting Form

Note: The initial Healthie GFE form shared with your account contains text that needs to be personalized for your business. Be sure to replace all text highlight in blue with your personal practice information on your initial editing of the form template (you can do this in Form Builder). Your version of the form when shared as a charting note to your client's chart should reflect your own personal business information (no placeholder text).

2. Complete the GFE as a Chart Note

Go to your client's charting > New Chart Note > Select the GFE Charting Template
Client information like name and date of birth will automatically populated
Complete the remaining form details
Generate the Charting Note as a PDF and upload it to your client's documents (it will only be visible to your client)
Request that your client download the form, date & sign it, and re-upload it to their Documents. You can share this client resource with your client to walk them through how to download and upload a Document.

Learn more about uploading a private document to a client's chart, and having client's upload documents here.

Issuing Another GFE for a Client

If there are other services rendered (ie. at another date) then you will be required to complete/send another GFE on behalf of your client. You can restart the process by again requesting form completion for the Good Faith Estimate form. It will create another (separate) instance of the form within their account.

Again complete the office-only information, and ask your client to date and e-sign the form.

If you are providing the same services to your client, and your Good Faith Estimate rates have not changed, you likely do not need to have your client complete the same form again. Consider issuing a new GFE when services or procedures are expected to change.

Clients Without an Email Address Completing the Form

Follow the same steps to share the GFE form with your client's account.

Fill Out the form as described above.

If your client is attending an in-person session, you can have the form already loaded (ie. from a computer, ipad, or other device in your office), and you can allow the client to date and e-sign at that time.

Alternatively, you can download a PDF version of the form, and have the client sign a hard copy. In this case, we suggest that you scan and load the signed form into your client's Documents folder.

Additional Resources

You can find more information on the No Surprises Act and Good Faith Estimate requirements on the CMS website

https://www.cms.gov/nosurprises

Many professional organizations have issued their own statements regrading both items. Please refer to your professional organization for the latest details.

Have feedback or questions? We'd be happy to hear from you. Please email us hello@gethealthie.com