No Surprises Act · Effective January 1, 2022 · Required for all uninsured & self-pay patients

The Good Faith Estimate
generator built for
dermatology practices.

Federal law requires Good Faith Estimates for uninsured and self-pay patients. DermEstimator generates a fully-compliant GFE document in one click — no Word templates, no manual PDFs, no compliance guesswork.

No Surprises Act–compliant NSA language pre-loaded Audit-ready storage
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Background

What is a Good Faith Estimate?

The No Surprises Act, signed into law in 2020 and effective January 1, 2022, requires healthcare providers to give uninsured and self-pay patients a written cost estimate — called a Good Faith Estimate — before any scheduled non-emergency service.

01

Who receives a GFE?

Any uninsured or self-pay patient who schedules a service must receive a GFE. This includes patients without insurance coverage, patients who choose to pay out of pocket, and patients whose plan does not cover the service being performed.

02

When must it be issued?

For scheduled services, the GFE must be provided at least 1 business day before the appointment. For services scheduled more than 10 business days in advance, at least 3 business days before. It can be delivered electronically if the patient consents.

03

What is the $400 rule?

If the final bill exceeds the Good Faith Estimate by more than $400, the patient has the right to dispute the bill through a federally-sanctioned Patient-Provider Dispute Resolution process. Practices have 120 days from the initial bill date to resolve the dispute.

04

What are the penalties?

HHS can impose civil monetary penalties up to $10,000 per violation for providers who fail to issue Good Faith Estimates. CMS enforcement guidance is actively being updated, and audits are ongoing. Compliance is not optional.

Federally Required Elements

What a GFE must include.
We handle all of it.

A compliant Good Faith Estimate has many required fields. DermEstimator populates every mandatory element automatically from your estimate data — nothing falls through the cracks.

  • Patient name, date of birth, and contact information
  • Itemized list of services with CPT/HCPCS codes and plain-language descriptions
  • Expected charge for each individual service
  • Diagnosis codes (ICD-10) where available
  • Rendering provider name and NPI number
  • Practice facility name, address, and NPI
  • Patient rights notice: $400 dispute threshold and 120-day dispute window
  • SDR (Selected Dispute Resolution) entity contact information
  • Total estimated amount and date of service
📄 GFE-2026-04291547
Patient: Jane Doe
DOB: 03/14/1968
11102 · Tangential biopsy
17000 · Destruction
Total: $187.39
Provider NPI: ✓
Facility NPI: ✓
$400 dispute right ✓
120-day window ✓
SDR process ✓
Generated in 60 seconds
How DermEstimator Does It

From estimate to compliant GFE
in three steps.

No separate workflow. No extra software. The GFE flows directly from the estimate you already built.

01

Build the estimate as usual

Select the patient's payer, add the procedures planned for the visit, and enter cost-share details. DermEstimator calculates the itemized breakdown — exactly what you already do for every patient quote.

02

Click "Generate GFE"

One click converts the estimate into a fully-compliant Good Faith Estimate document. All required NSA language is pre-loaded and locked — you cannot accidentally omit a required field. Your practice letterhead and customizable intro/closing are applied automatically.

03

Deliver and store

Print or email the GFE to the patient — or hand them the printed copy at the front desk. DermEstimator stores a permanent, audit-ready snapshot of every issued GFE so you have a timestamped record if a dispute ever arises.

Good Faith Estimate FAQ

Common questions about GFEs
and the No Surprises Act.

What is a Good Faith Estimate (GFE)?
A Good Faith Estimate is a written notice that healthcare providers are required to give uninsured and self-pay patients before a scheduled service. Under the No Surprises Act (effective January 1, 2022), providers must issue a GFE with itemized expected costs, the provider's name and NPI, and information about the patient's right to dispute a bill that exceeds the estimate by more than $400.
Which dermatology patients require a Good Faith Estimate?
Any uninsured or self-pay patient who schedules a non-emergency service is entitled to a GFE. This includes patients who are uninsured, patients who choose not to use their insurance for a visit, and patients whose plan does not cover a particular service. The GFE must be provided at least 1 business day before the scheduled service.
What happens if our bill is more than $400 over the GFE?
The patient has the right to initiate a Patient-Provider Dispute Resolution process. A neutral Selected Dispute Resolution (SDR) entity reviews the case. The patient has 120 calendar days from the date of the initial bill to dispute. Practices that issue accurate GFEs through DermEstimator significantly reduce this risk because estimates are based on the official 2026 MPFS rates.
Does DermEstimator include all required NSA language automatically?
Yes. All federally-required patient rights language — including the $400 dispute threshold notice, the 120-day window, and the SDR entity reference — is pre-loaded and locked in every GFE DermEstimator generates. The locked fields cannot be edited or removed, ensuring every GFE is compliant.
Can we customize the GFE with our practice letterhead?
Yes. In Settings, practices upload their logo, set their letterhead text, and customize the introductory and closing paragraphs. These practice-specific elements are applied to every GFE. The required federal language sections remain locked and cannot be overridden.
Is a GFE required for insured patients too?
The federal GFE requirement under the No Surprises Act applies specifically to uninsured and self-pay patients. For insured patients, the Advanced Explanation of Benefits (AEOB) rules apply — though those provisions have a separate implementation timeline. DermEstimator's estimate functionality is available for all payers, not just self-pay.
Do we need a separate GFE template or Word document?
No. DermEstimator eliminates the need for Word templates, Google Docs, or manual PDFs. The GFE is generated directly from the estimate with all required federal language intact. You customize the practice-specific sections once in Settings, and DermEstimator handles every GFE from that point forward.

Ready to get compliant?

Stop relying on Word templates and hope. DermEstimator generates federally-compliant Good Faith Estimates the moment you finish quoting — with every required element, your branding, and a permanent audit record.

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