Your right to a Good Faith Estimate
Under the No Surprises Act, health care providers must give patients who do not have insurance, or who are not using insurance, an estimate of the expected charges for medical and mental health services before the services are provided.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like therapy sessions, group therapy, and other services we provide.
How to request a Good Faith Estimate
You can ask Pasadena Clinical Group for a Good Faith Estimate before scheduling a service or at any time during care. If you are scheduling care, we will provide a Good Faith Estimate in writing at least one business day before your service. You may also request a Good Faith Estimate from us before scheduling a service.
What's included in a Good Faith Estimate
The Good Faith Estimate will show, in writing, the costs of items or services that are reasonably expected for your care. The estimate will include:
- Your name and date of birth;
- A description of the service expected (e.g., individual therapy, group therapy);
- An itemized list of items and services we expect to provide;
- Diagnosis codes, service codes, and expected charges;
- The provider or facility's name, NPI, and tax identification number;
- State(s) in which the services will be provided.
If your bill exceeds the estimate by $400 or more
If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill through the federal patient-provider dispute resolution process. To dispute a bill, follow the instructions you'll receive with the final bill, or visit www.cms.gov/nosurprises.
You must start the dispute process within 120 calendar days 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 the Good Faith Estimate. If the agency disagrees with you and agrees with the provider, you will have to pay the higher amount.
Limitations of a Good Faith Estimate
A Good Faith Estimate is not a contract. It does not require you to obtain the services from us. The estimate is based on information known at the time the estimate was created. It does not include unforeseen circumstances or additional services that may be needed and were not reasonably expected at the time of the estimate.
The Good Faith Estimate process applies only to self-pay and uninsured patients. If you are using insurance, your costs will be based on your specific plan benefits, copays, deductibles, and coinsurance. Our care coordinator can verify your benefits before your first session.
More information
For more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.
Questions specific to our practice? Contact office@pasadenaclinicalgroup.com or call 626-354-6440.