The No Surprises Act in a dental office: the good faith estimate you owe self-pay patients, and the parts that never reach you

What it says#

The No Surprises Act is Title I of Division BB of the Consolidated Appropriations Act, 2021, signed December 27, 2020. Most of it is about surprise medical bills: it bars balance billing for emergency services, for non-emergency care at in-network hospitals, hospital outpatient departments and ambulatory surgical centers, and for air ambulance. CMS's consumer page lists exactly those three settings. None of them is a dental office.

Section 112 is the part that does reach a dental office. It added section 2799B-6 to the Public Health Service Act, which says that beginning January 1, 2022, each health care provider and facility, when an individual schedules an item or service at least 3 business days ahead, must ask whether the person is enrolled in a health plan, coverage or federal program, and provide "a notification (in clear and understandable language) of the good faith estimate of the expected charges." When the patient is not enrolled, or is enrolled but is not submitting a claim, the estimate goes to the patient. HHS wrote the details into 45 CFR 149.610 in the October 7, 2021 interim final rule, Requirements Related to Surprise Billing; Part II.

The rule defines a health care provider as "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." An uninsured (or self-pay) individual is anyone without benefits for the item or service under a group health plan, individual or group insurance coverage, a federal health care program or the federal employees' plan, and anyone who has such benefits "but who does not seek to have a claim for such item or service submitted." The office that schedules the primary service is the convening provider.

The convening provider must inform every uninsured or self-pay patient that an estimate is available, with the information "prominently displayed (and easily searchable from a public search engine) on the convening provider's or convening facility's website, in the office, and on-site where scheduling or questions about the cost of items or services occur," and stated orally when scheduling or when cost questions come up. Any discussion of the potential cost of care counts as a request. The estimate is due within 1 business day of scheduling when the service is scheduled at least 3 business days out, within 3 business days when it is scheduled at least 10 business days out, and within 3 business days of a request. It must be in writing, on paper or electronically in a form the patient can save and print, and it must list the patient's name and date of birth, a description of the primary service, an itemized list of expected items and services with diagnosis codes, service codes and expected charges, the provider's name, NPI and TIN, anything that will be scheduled separately, and disclaimers including the right to the dispute process and a statement that the estimate is not a contract. If the scope changes, a new estimate is owed no later than 1 business day before the visit. The estimate is part of the medical record, and a copy of any estimate issued in the last 6 years must be provided on request.

The dispute process in 45 CFR 149.620 opens when the billed charges are "substantially in excess" of the estimate, which HHS's FAQs interpret as $400 or more, for that provider. CMS's consumer page says the patient has 120 days from the initial bill to start it. While a dispute is open, the model notice says, the provider cannot send the disputed item to collections, must suspend late fees, and cannot retaliate.

Who it applies to#

Any dental office that schedules an uninsured or self-pay patient, which is every dental office. HHS's first FAQ on the subject, from December 2021, answered the question directly: "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." Part 5 of the FAQs, three years later, said it again for dental and vision providers by name.

Self-pay is broader than uninsured. A patient with a dental benefit who chooses to pay cash, because the procedure is not covered or the fee is lower, is self-pay under the rule. HHS's Part 5 FAQ adds that members of health care sharing ministries and holders of short-term limited-duration insurance, self-funded student plans and farm bureau plans are uninsured for this purpose. The FAQs do not address in-house dental membership plans; the definition turns on enrollment in a group health plan, insurance coverage or a federal program.

Two things do not apply. A booking made fewer than 3 business days before the visit, including a walk-in or an emergency, does not require an estimate unless the patient asks, and Part 5 says an estimate given voluntarily in that situation does not qualify the patient for the dispute process. And the estimate is single-provider for now: HHS said in the 2021 rule that it would not enforce the requirement to include co-provider and co-facility charges through the end of 2022, extended that in December 2022 "pending future rulemaking," and the CMS consumer page, last modified August 25, 2026, still tells patients that "good faith estimates only list expected charges for a single provider or facility." If you refer the patient to an oral surgeon, that office owes its own estimate.

What changed#

Before 2022 no federal rule told a dental office what to hand a cash patient before treatment. Since January 1, 2022 there is a form with required contents, a delivery clock measured in business days, a posting requirement and a dispute mechanism with a dollar threshold. What has not changed since is the enforcement posture on the harder pieces: the co-provider consolidation has been unenforced for four years running, and the plan-facing estimate for insured patients that the statute also describes was the subject of a September 2022 request for information, not a rule an office can follow.

The dispute process is the practical exposure. A patient with a written estimate and a bill $400 or more above it has a federal process to invoke, and an estimate that was never given, or was given orally, is the thing an office cannot defend. Part 5 adds that business days are Monday through Friday excluding federal holidays, the estimate is due by 11:59 PM on the day it is owed, and a request made to anyone in the office whose job touches scheduling or billing is a valid request.

Where the source is#

CMS's provider requirements page in its No Surprises section links the FAQs, model notices and training slides; the rule itself is 45 CFR 149.610 on eCFR and the statute is 42 U.S.C. 300gg-136 on the House Office of the Law Revision Counsel's site. The five HHS FAQ documents on good faith estimates (December 2021 through December 2024) and the June 2023 model notices are free PDFs on cms.gov. The interim final rule, 86 FR 55980, is on govinfo. CMS's consumer pages at cms.gov/medical-bill-rights carry the $400 and 120-day figures in plain language. All of it is public domain.