No Surprises Act Disclosure 

Beginning Jan 1, 2022, per the “No Surprises Act,” you have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who do not have insurance or who are not using insurance an estimate of the bill for medical items and services. 

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 medical tests, prescription drugs, equipment, and hospital fees. 

Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service. 

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. 

• You may contact the health care provider or facility listed to let them know the billed charges are higher than the GFE. You may ask them to update the bill to match the GFE, negotiate the bill, or ask if financial assistance is available. 

• 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 the dispute process within 120 calendar days (about four 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 GFE. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. 

Make sure your health care provider gives you a Good Faith Estimate within the following timeframes:

• If the service is scheduled at least three business days before the appointment date, no later than one business day after the date of scheduling;

• If the service is scheduled at least ten business days before the appointment date, no later than three business days after the date of schedule; or

• If the uninsured or self-pay client requests a GFE (without scheduling the service), no later than three business days after the date of the request. Healthcare providers must supply a new GFE within the specified timeframes if the patient reschedules the requested item or service. Make sure to save a copy or picture of your Good Faith Estimate 

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

Psychiatric medication management is a very individualized process and the length of services vary depending upon clinical needs and goals. There are no time-specific constraints for the duration of your care, and you can stop at any time. My recommendations for the duration of treatment and session frequency are determined by a reduction in your distress/symptoms and treatment plan progress which will continually be assessed, but you ultimately make the decision on how often you attend appointments. 

If your treatment duration is longer than one year, a new 

Good Faith Estimate will be furnished at the 12 month mark. 

For questions about your good faith estimate or to dispute a bill please contact us by phone or email.

admin@rainbowmentalhealthsvcs.com

(224) 263-4671