What Is the $400 Good Faith Estimate Rule in 2026?

Synthetic-only notice: Every amount and scenario below is illustrative. It is not drawn from a real bill and contains no real patient, provider, insurer, diagnosis, account, or payment information.

The short answer

The federal Good Faith Estimate rule can help some people who pay for care without using health insurance. When the rule applies, a provider or facility generally must give the person a written estimate of expected charges before scheduled care. If one provider or facility later bills at least $400 more than its own estimate, the person may qualify for the federal patient-provider dispute resolution process, often shortened to PPDR.

The rule is narrower than the phrase “$400 rule” can make it sound. It is not a general appeal for every medical bill. It does not apply merely because a total bill is high, and it is not the same process used to appeal an insurer's coverage decision. Eligibility depends on how the care was paid for, when it occurred, whether a written estimate exists, when the initial bill was issued, and how each provider's bill compares with that provider's estimate.

If you used insurance, start by comparing the provider bill with the plan's Explanation of Benefits. Our guide to reading an EOB line by line explains that separate path. Definitions of Good Faith Estimate, allowed amount, balance billing, and related terms are also available in the medical billing glossary.

Who generally qualifies for a Good Faith Estimate?

The rule generally covers two groups:

• Uninsured people: For this rule, that generally means a person who is not enrolled in a group health plan, individual health insurance, a federal health care program, or a Federal Employees Health Benefits plan.
• Eligible self-pay people: A person with group, individual, or FEHB coverage may be treated as self-pay when they tell the provider before care that they do not want a claim submitted to that coverage for the item or service.

There is an important federal-program exclusion. CMS guidance says a person enrolled in Medicare, Medicaid, CHIP, TRICARE, or the VA health care system is not considered uninsured or self-pay for this particular Good Faith Estimate rule, even if the program does not cover the service or the person does not want a claim submitted. Those programs may provide other billing and appeal protections, but they are not the PPDR route described on this page.

The current CMS dispute page also limits PPDR to qualifying care received on or after January 1, 2022. Before relying on the process, use the current CMS eligibility information or call the No Surprises Help Desk at 1-800-985-3059.

When must the estimate be provided?

Timing depends on when care is scheduled or when an estimate is requested:

• If care is scheduled 3 to 9 business days in advance, the provider or facility generally must issue the estimate within 1 business day after scheduling.
• If care is scheduled 10 or more business days in advance, it generally must issue the estimate within 3 business days after scheduling.
• If an eligible person requests an estimate before scheduling, the provider or facility generally must provide it within 3 business days after the request.

A Good Faith Estimate is generally not required for emergency care, a walk-in visit, or care scheduled only 0 to 2 business days in advance. CMS also says that a discussion or question about the potential cost of care can count as a request, but making the request clearly and retaining the written response reduces later uncertainty.

It must be written, not only discussed

The estimate should be provided in the person's preferred written form, either on paper or electronically. A provider may also explain the estimate by telephone or in person, but an oral figure does not replace the written document needed for PPDR.

The written estimate should itemize the expected charges for the scheduled items and services from the provider or facility issuing it. One estimate may not capture every participant in an episode of care. For example, a facility and an independently billing clinician may issue separate estimates. Additional services scheduled separately, services from another organization, and genuinely unanticipated care may not appear on the original document.

Keep every estimate and the initial bill. Do not upload those records to a public forum. They can contain identifiers and sensitive health or account information.

How the per-provider $400 test works

The threshold is applied to each provider or facility, not simply to the combined total for an episode of care.

Consider this entirely synthetic example:

The combined bills are $800 above the combined estimates, but that is not the test. The facility's charge is $450 above its own estimate and may be eligible. The clinician's charge is only $350 above its estimate and does not meet the federal PPDR threshold.

“At least $400 more” includes a difference of exactly $400. A lower difference may still be worth reviewing for an ordinary billing error, financial assistance, a plan appeal, or rights under state law, but it does not meet this federal dollar test. The common medical bill errors guide explains what to compare before assuming a price difference is valid.

Other requirements for the federal dispute process

CMS currently lists these core conditions for PPDR:

1. You did not have insurance or did not use eligible insurance to pay for the care.
2. You told the provider before care that insurance would not be used.
3. The care occurred on or after January 1, 2022.
4. You received and retained the required written Good Faith Estimate before care.
5. The initial bill is within the 120-calendar-day filing period.
6. At least one provider or facility billed at least $400 more than its own estimate.

The current CMS consumer page describes receiving the estimate before the scheduled appointment as part of eligibility. If the timing of your estimate was unusual or close to the appointment date, do not guess. Use the official CMS checker or Help Desk.

The 120-day deadline and $25 fee

The PPDR initiation notice must be sent within 120 calendar days of the date on the initial bill. CMS describes this as about four months, but the calendar-day rule controls. Save the first bill and record its date.

You may contact the provider, ask it to correct the bill, negotiate, or apply for assistance during that period. Those are separate options. Do not assume any of them extends or pauses the federal 120-day filing deadline.

CMS currently charges a $25 non-refundable administrative fee to file. The process does not begin until the fee is paid. If the decision favors the consumer, CMS says the provider must credit that $25 against the amount the consumer owes. That credit does not turn the filing fee into a cash refund.

An independent reviewer evaluates the estimate, bill, and supporting information. The reviewer may reduce the amount, select another amount, or leave the bill unchanged when added charges were appropriate under the governing rules. Filing a dispute is not a guarantee of a reduction.

When collection protection begins

The strongest collection statement must be tied to an active PPDR case. Once the federal dispute process is underway, the provider or facility may not:

• move the disputed bill into collections or threaten to do so;
• continue pursuing payment if that disputed bill is already in collections;
• collect existing late fees on the unpaid disputed amount while the process is pending; or
• retaliate or threaten retaliation because the person initiated PPDR.

This is more precise than saying a qualifying bill is automatically “frozen.” A large difference, a telephone call, an ordinary written objection, a financial-assistance application, or a No Surprises complaint is not by itself the same as initiating PPDR.

If the provider and consumer settle after PPDR begins but before the reviewer decides, CMS says the provider must reduce the bill by at least $12.50 and notify the reviewer. Outside that specific situation, there is no official percentage reduction that a provider must offer.

What if no Good Faith Estimate was provided?

CMS says the federal PPDR route cannot be used without a written Good Faith Estimate. If you believe one should have been provided, first ask whether the provider issued it and request a copy. Do not assume an estimate created after the bill will retroactively establish eligibility.

If no estimate exists, you can submit a No Surprises complaint. A complaint helps CMS investigate compliance, but CMS states that the consumer remains responsible for the bill while that complaint is handled. Filing a complaint does not automatically create PPDR collection protection.

Other paths may still be available:

• ask the billing department for a detailed bill and check it for mistakes;
• compare a bill with the EOB if insurance was actually used;
• request the facility's financial assistance policy and application;
• ask whether a lower self-pay amount or payment plan is available; or
• check state consumer and insurance protections.

For a structured review of those choices, see how to dispute a medical bill and how to negotiate a hospital bill.

A practical checklist

1. Confirm the payment path. Determine whether insurance was submitted and whether the federal uninsured/self-pay definition fits.
2. Match each organization separately. Pair every provider or facility estimate with that party's bill.
3. Calculate each difference. Subtract that party's expected charge from its billed charge.
4. Check dates. Record the care date, estimate date, scheduling date, and initial-bill date.
5. Preserve private copies. Keep the estimate and bill securely; do not post or email them to unknown services.
6. Use the CMS eligibility page. Confirm that the current rules still match your situation.
7. Protect the deadline. If pursuing PPDR, initiate within 120 calendar days rather than waiting for informal talks to finish.
8. Keep options separate. A complaint, plan appeal, provider correction, financial-assistance request, and PPDR serve different purposes.

Sources

• CMS: What is a Good Faith Estimate?
• CMS: Dispute a medical bill
• CMS: Who is uninsured or self-pay for this rule?
• CMS: Know your rights when not using insurance
• CMS: Provider obligations during patient-provider dispute resolution
• CMS: Sample Good Faith Estimate and dispute notice