The No Surprises Act, enacted as part of the Consolidated Appropriations Act, 2021, restricts balance billing in specified out-of-network situations and requires good faith estimates for uninsured and self-pay patients. For a dental group the honest summary is: the balance-billing protections the Act is famous for mostly do not reach routine dentistry, the good faith estimate requirement probably does reach your self-pay patients, and facility-based out-of-network oral surgery billed to medical plans can implicate the full statute.
The Act’s implementing regulations and dispute-resolution processes have been repeatedly litigated and amended since 2021, and how they apply to dental practices is less settled than the medical guidance suggests. Verify current requirements with counsel before relying on specifics.1
Why the balance-billing rules mostly miss dentistry
The Act’s surprise-billing protections apply to items and services covered by group health plans and health insurance issuers, generally the patient’s medical coverage, in emergency and in-network-facility scenarios. Routine dentistry usually sits outside that framework for two reasons:
- Dental benefits usually come through standalone dental plans, which are generally treated as excepted benefits rather than group health coverage. The Act’s balance-billing protections were written for medical-plan coverage. Ask counsel to confirm the excepted-benefits boundary under the relevant state law and payer contracts.
- The usual office visit does not match the classic surprise-bill scenario. A patient who selects an out-of-network dentist for a crown is in a different position from a patient who unknowingly receives care from an out-of-network clinician at an in-network facility. The plan’s out-of-network benefit and the patient’s payment agreement generally govern office-based dental care. See Patient responsibility.
Where dentistry does get caught
Facility-based oral surgery billed to medical. An out-of-network oral and maxillofacial surgeon providing services at an in-network hospital or ambulatory surgery center and billing the patient’s medical plan can fall within the Act’s core scenario. Emergency-department dental trauma care billed to medical may also be covered. If your group includes oral surgeons who work in facilities, review the notice-and-consent rules, cost-sharing limits, and independent dispute resolution process with a specialist. These requirements have changed repeatedly. See Oral surgery and implants and Bill medical for dental work.
Good faith estimates for uninsured and self-pay patients. This provision reaches ordinary dental practices. Providers must furnish a good faith estimate (GFE) of expected charges to uninsured and self-pay individuals who schedule an item or service or request an estimate. The implementing definition of “provider” is broad enough to include licensed dentists. Membership-plan patients may count as self-pay when no insurance claim will be filed. Treat the GFE requirement as applicable to the practice’s self-pay patients unless counsel confirms otherwise for the relevant facts and states.
Good faith estimates in practice
What a GFE generally must include:
- Patient name and date of birth
- A description of the primary item or service, and the scheduled date
- An itemized list of items and services reasonably expected, grouped by provider or facility
- Applicable service codes with expected charges
- Provider names, NPIs, and TINs
- A disclaimer that the estimate is not a contract and that actual charges may differ
Timing requirements are keyed to when the service is scheduled or the estimate is requested, with shorter windows for near-term scheduling. There is also a patient-provider dispute resolution process where billed charges substantially exceed the estimate. Confirm the current timing rules.
Dental practices already present written treatment estimates before major work, and many obtain predeterminations for insured patients. A GFE adds federal content and timing requirements to a familiar workflow.
Build the GFE into scheduling, not into billing. It is triggered by scheduling or a request, not by a claim. Practices that treat it as a billing function generate them late or not at all. If your PMS produces treatment-plan estimates, adapt that output to the GFE content requirements rather than building a parallel document.
What to do about it
Every dental group:
- Implement good faith estimates for uninsured and self-pay patients, including membership-plan patients
- Keep the distinction clear internally. Federal law requires a GFE for self-pay patients, while a predetermination is a voluntary payer estimate for insured patients. See Get predeterminations
- Verify state law: some states have their own patient-estimate and balance-billing statutes that reach dental care directly
Groups with oral surgeons in facility settings:
- Map which service lines and facilities trigger the Act’s balance-billing protections on the medical side
- Implement notice and consent where available, and use a specialist for the out-of-network rate process because the arbitration mechanics have changed repeatedly
Sources
- No Surprises Act, Consolidated Appropriations Act, 2021, Pub. L. 116-260, div. BB, tit. I. CMS, No Surprises Act overview and Good Faith Estimates. Implementing regulations at 45 C.F.R. pts. 149, 150 and parallel provisions. Verify current requirements because the regulations and dispute-resolution processes have been repeatedly amended and litigated. Confirm the Act’s application to standalone dental coverage with counsel.