Self-Pay & Good Faith Estimates

SELF-PAY CLIENTS are provided GOOD FAITH ESTIMATES, a requirement of The No Surprises Act, Effective January 1, 2022

The Good Faith Estimate shows the costs of items and services that are expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.

Clients, upon request or at the time of scheduling appointments, shall receive a “Good Faith Estimate” of expected charges.

Good Faith estimates are an estimate of the total expected cost of any non-emergency treatment or services.

An estimate of certain, “add-on” services that help support progress and success, when appropriate.

Customized estimates that are in writing at least one (1) business day before the scheduled appointment, if the appointment is scheduled within 3 business days.

Customized estimates that are in writing at least three (3) business days before the scheduled appointment, if the appointment is scheduled within 10 business days.

Customized estimates for inquired-about, but not yet scheduled, services.

Customized estimates include:

Client name

Client date of birth

Description of the services that will be provided, in understandable language

Itemized list of services expected to be provided in connection with the scheduled services

Diagnostic codes, service codes, and expected charges associated with each of those services

Provider name, NPI, and tax ID number

Office location where services will be provided

If the client receives a bill that is at least $400 more than the Good Faith Estimate, the bill can be disputed.

The client shall be sure to access the client portal to review this agreement and should download and keep a copy of the good faith estimate.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. The client could be charged more if complications or exceptional circumstances occur.

If the client is billed for more than the Good Faith Estimate, the bill can be disputed.

The client may contact the health care provider to talk about billed charges that appear higher than the Good Faith Estimate. The client may ask for an update on the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

The client may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). The dispute process should start 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 the dispute agrees with the dispute, the client will have to pay the price on the Good Faith Estimate. If the agency agrees with the bill, the client will have to pay the higher amount.

For questions or more information about the Good Faith Estimate or to start the dispute process, the client may visit www.cms.gov/nosurprises or call 1-800-985-3059