Good Faith Estimate

Good Faith Estimate Notice

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the No Surprise Act, health care providers must provide uninsured patients, or self-pay patients, an estimate of the expected charges for medical services, including psychotherapy services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. The Good Faith Estimate will also include items or services reasonably expected to be provided along with the primary item(s) or service(s), even if the individual will receive the items and services from another provider or another facility.

Requesting a Good Faith Estimate

You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate for a scheduled or requested item or service. You could be charged more if complications or special circumstances occur. If this happens, and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that provider or facility, federal law allows you to dispute the bill.

Keep a copy of your Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

The Good Faith Estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

If You Are Billed More Than the Estimate

If you are billed for more than this Good Faith Estimate, you may have the right to dispute 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
• Ask if financial assistance is available

Dispute Resolution Process

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 within 120 calendar days (about 4 months) of the date on the original bill.

If you dispute your bill:

• The provider or facility cannot move the disputed bill into collection or threaten to do so.
• If the bill is already in collection, collection efforts must cease.
• Late fees must be suspended until after the dispute process concludes.
• The provider or facility cannot take or threaten retributive action against you for disputing your bill.

There is a $25 fee to use the dispute process. If the Selected Dispute Resolution (SDR) entity agrees with you, you will pay the Good Faith Estimate amount minus the $25 fee. If the SDR entity agrees with the provider or facility, you will be responsible for the higher amount.

To learn more and get a form to start the process, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059.

Questions or More Information

For questions or more information about your right to a Good Faith Estimate or the dispute process:

• Visit www.cms.gov/nosurprises/consumers
• Email: [email protected]
• Call: 1-800-985-3059