Good Faith Estimate

The No Surprises Act

Effective January 1, 2022, the No Surprises Act (Public Law No. 116-260) is a federal law that requires healthcare providers and healthcare facilities to give patients who do not have insurance or who choose not to use their insurance an estimate of expected charges for medical services, including psychotherapy and counseling services.

Under this law, you have the right to receive a Good Faith Estimate (GFE) for the total expected cost of any non-emergency healthcare services, including mental health services provided by Serenity Mind Wellness.

What Is a Good Faith Estimate?

A Good Faith Estimate is a written document that provides an estimate of the expected costs for healthcare services you are scheduled to receive or that you have requested information about. It is designed to help you understand and plan for your expected healthcare costs before you receive care.

Your Good Faith Estimate will include:

• A list of expected services and their associated costs
• The expected frequency and duration of therapy sessions
• Diagnosis codes, if applicable
• Service codes (CPT codes) for each expected item or service
• The name and National Provider Identifier (NPI) of your provider
• Any applicable disclaimers regarding the estimate

Your Rights Under the No Surprises Act

As a patient, you have the right to:

• Receive a Good Faith Estimate for the total expected cost of healthcare services upon scheduling or upon request
• Receive the estimate in writing at least 1 business day before your scheduled service (or within 3 business days after requesting one)
• Dispute a bill if the actual charges are substantially higher (at least $400 more) than the Good Faith Estimate
• Request an updated estimate at any time during your course of treatment

How to Request a Good Faith Estimate

You can request a Good Faith Estimate before you schedule a service or at any time during your treatment. To request an estimate:

• Call our office at (555) 123-4567
• Email us at hello@serenitymindwellness.com
• Ask your clinician during any appointment

If you schedule a service at least 3 business days in advance, we will provide you with a Good Faith Estimate within 1 business day after scheduling. If you schedule a service at least 10 business days in advance, we will provide the estimate within 3 business days after scheduling.

Dispute Resolution Process

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. You may contact our office to discuss the charges and negotiate the bill. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS).

To initiate the dispute process:

• You must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill
• A $25 fee may be required to use the dispute resolution process (this fee may be refunded if the dispute is resolved in your favor)
• If the agency reviewing your dispute agrees with you, you will only have to pay the Good Faith Estimate amount

For more information about the No Surprises Act and the dispute resolution process, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Questions?

If you have questions about Good Faith Estimates, the No Surprises Act, or the cost of our services, please do not hesitate to contact us. We believe in transparency and are happy to discuss fees and payment options with you.