Good Faith Estimate Templates for Audiologists and Speech-Language Pathologists

A Good Faith Estimate (GFE) form is used by private practices or clinics to provide their best judgment of the estimated cost of care based on a patient’s projected plan of care. It is required by the No Surprises Act (P.L. 116-260) for providers with patients who are either not insured (i.e., self-paying) or not choosing to bill their insurance plan directly (i.e., considered out-of-network). The estimate can include a range in terms of numbers of visits and codes billed since a plan of care may change based on several factors, including patient progress, patient adherence to treatment, or other comorbidities that a patient may experience. The Department of Health and Human Services (HHS) has published a provider guidance document [PDF] to help in your compliance with the new regulation.

The components of a GFE form should include the following

Patient name
Patient date of birth
Description of the services you will provide
Detailed list of services and any equipment or materials you expect to provide
Diagnosis codes, procedure codes, and expected charges associated with each of those goods or services

Corresponding charges can be listed per individual procedure code or as a visit type (e.g., hearing evaluation, speech and language treatment)

Provider name, NPI, and tax ID number
Location where you will provide services

Some disclaimers to consider are:

As treatment continues, the therapy needs of the patient may change and the provider may suggest additional or different services to be included in the treatment. A new Good Faith Estimate can be requested at any time.
The information provided in this estimate is not a guarantee of cost, but an estimate based on clinical expertise and evaluation of the specific patient. Actual costs and services may differ.
The patient has the right to engage in a dispute resolution process if the actual costs of services “significantly exceed” those listed in the Good Faith Estimate. (More than $400 over the estimate, per session.)
The patient has the right to choose whether they move forward with all, or part of the treatment suggested. Signing this document doesn’t obligate them to receive services.

Please review No Surprises Act Goes into Effect 2022 for more information on GFE implementation considerations.

Good Faith Estimate Templates

ASHA developed downloadable GFE templates (below) as a tool for audiology and speech-language pathology practices. Each template provides suggested language and a format for presenting the estimated cost of care using established rates associated with billing codes, including:

Current Procedural Terminology (CPT ® American Medical Association) codes that describe audiology and speech-language pathology procedures and services (diagnostic testing or therapy, for example)
Healthcare Common Procedure Coding System (HCPCS) Level II codes that describe prosthetic and durable medical equipment (e.g., hearing aids and related services, speech-generating devices) and some procedures used by audiologists and speech-language pathologists (SLPs)

The templates also include space to report the primary and secondary International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes that describe the patient’s diagnosis or presenting complaint and symptoms. Comprehensive lists of diagnosis codes developed specifically for audiologists and SLPs are available on ASHA’s ICD-10 webpage.

Important Notes About the Templates

It is acceptable if your practice prefers not to list costs per billing code and, instead, chooses to list rates associated with visit type. (e.g., hearing evaluation, speech and language treatment). Your practice can use a superbill to provide additional details on actual charges and services provided after a visit(s).
ASHA recommends including a comprehensive list of billing codes for services the patient may receive during an episode of care even though not every code will be reported at every visit. The billing codes listed in each template are only included for illustrative purposes.
If you are unsure what diagnosis code(s) to include before you evaluate the patient, code based on the patient’s chief complaint, signs, symptoms, or reason for the visit. You may also use the referring physician’s initial diagnosis, if available and appropriate.
ASHA provides sample language outlining the final total of charges for the full episode of care, if you wish to include it in your GFE. However, CMS does not explicitly state the need for a final total.

Downloadable Templates

Each template is customizable to fit the needs of your practice and can be filled out electronically or by hand.

Note: ASHA’s good faith estimate template is only a model. It does not dictate which services should or should not be listed on the estimate and does not imply medical necessity. All procedures, billing codes, or other pertinent information are not included in the model.