Under federal law (the No Surprises Act, 45 CFR §149.610), healthcare providers must give clients without insurance, or who are not using insurance, a written estimate of expected charges before scheduling care. This page summarizes our practice's compliance with that requirement.
Your right to a Good Faith Estimate
You have the right to receive a Good Faith Estimate of the expected charges for the medical and mental health services you will receive. This applies if you are uninsured or have insurance but choose not to use it.
Specifically:
- You can ask us, or any other provider, for a Good Faith Estimate before you schedule a service or anytime during care.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill through the federal patient-provider dispute resolution process.
- Make sure to save a copy or picture of your Good Faith Estimate.
How and when we provide the estimate
For psychotherapy services, we provide a written Good Faith Estimate:
- Within 1 business day if scheduling occurs at least 3 business days in advance.
- Within 3 business days if scheduling occurs 10 or more business days in advance.
- Upon request at any time, including before scheduling.
What the estimate includes
- Provider name and contact information.
- Service codes (CPT) and descriptions.
- Diagnosis codes (ICD-10) where applicable.
- Expected charges per service and the total expected charges.
- The expected period of services (typically 12 months).
- A disclaimer that this is an estimate and that actual charges may differ.
Standard fees (as of effective date)
For self-pay clients, our standard rates are listed in your individual Good Faith Estimate. Sliding-scale arrangements are available on a case-by-case basis — please ask.
Dispute resolution
If you receive a bill that exceeds the Good Faith Estimate by $400 or more, you may initiate the federal patient-provider dispute resolution (PPDR) process within 120 days of receiving the bill. The process is administered by the U.S. Department of Health and Human Services. For details, visit cms.gov/nosurprises or call 1-800-985-3059.
Standard CMS notice
"You have the right to receive a 'Good Faith Estimate' explaining how much your medical care will cost. Under the law, healthcare providers need to give patients who don't 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 healthcare 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. 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 www.cms.gov/nosurprises or call 1-800-985-3059."
Selecting your provider
To request a Good Faith Estimate, please contact our billing office at (626) 354-6440 or office@pasadenaclinicalgroup.com.