According to newly implemented federal legislation, the Good Faith Estimate shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. The estimate is based on the information known to us when we prepared the estimate. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment (such as extra sessions, or insurance carriers not paying what is expected). You may be charged more if any complications or special circumstances occur.
You may contact the billing department if you determine that the billed charges are more than $400 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. In all cases, the billing department will work with you to achieve a satisfactory resolution to any problems that occur.
Feel free to contact the billing department by calling (516) 822-3131, or emailing firstname.lastname@example.org.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). This department only considers disputes that are more than $400 higher than the Good Faith Estimate. 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.
To learn more and get a form to start the process, go to: www.cms.gov/nosurprises or call CMS at 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059. Your Good Faith Estimate is not a contract.
Your specific Good Faith Estimate will be emailed to you from our billing department. Keep this email, or print it and save it in a safe place. You may need it if you are billed more than $400 higher than the Good Faith Estimate and you decide to dispute the amount.