Good Faith Estimate for Health Care Items and Services
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Under the federal No Surprises Act, uninsured or self-pay patients seeking non-emergency mental health services have the right to receive a Good Faith Estimate of expected charges for services, including psychotherapy. You may request a Good Faith Estimate before scheduling or at any time.
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Disclaimer
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This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The actual items, services, or charges may differ from the good faith estimate. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. There may be additional items or services that your provider recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate.
If the actual billed charges are substantially in excess of the expected charges included in the Good Faith Estimate, federal law allows you to dispute (appeal) the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
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You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. Initiation of the patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to you.
For questions or more information about your right to a Good Faith Estimate or the dispute process, or to get a form to start the process, go to www.cms.gov/nosurprises or call 1-800-985-3059.