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CMS Releases Model Language for No Surprises Act Forms

For CEOs, CFOs, government relations executives, finance & reimbursement staff, legal counsel

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The Centers for Medicare & Medicaid Services (CMS) has released a number of templated forms and model notices related to the No Surprises Act.  

These forms include the notices that must be provided to patients, a good faith estimate template, and documents related to the Patient-Provider Dispute Resolution (PPDR) process.  

Specifically, the materials include: 

  • Notice on Right to Receive a Good Faith Estimate: Hospitals and providers are required to inform uninsured individuals of their ability, upon request or at the time of scheduling services, to receive a good faith estimate of expected charges. While use of this model notice is not required, it may be used to inform patients of their rights. 
  • Good Faith Estimate Template: Hospitals and providers are required to provide a good faith estimate of expected charges for services to uninsured individuals upon request or at the time of scheduling. Use of this template is not required but is being provided by CMS to help facilitate compliance with the No Surprises Act. Also included in the documents released is a detailed description of the data elements required in the good faith estimate. 
  • PPDR Process: The No Surprises Act allows uninsured patients to initiate the PPDR process in instances where billed charges exceed the good faith estimate the patient received in advance of services by $400 or more. The released documents include the form patients will use to initiate the PPDR process, the notice Health and Human Services will use to notify providers the process has been initiated, and a notice used by providers if they come to a negotiated settlement of the dispute before the Selected Dispute Resolution entity renders a judgment.  

Additionally, CMS has released a memo providing a phone number for patient balance billing complaints (800-985-3059) and the website where the agency will be posting No Surprises Act implementation documents. Both the phone number and URL should be included in the model notice and consent form and model disclosure notice regarding patient protections against surprise billing.