Good Faith Estimate for Out of Network Providers:
Under the No Surprises Act (H.R. 133 – effective January 1, 2022), health care providers need to give clients or patients who do not have insurance or who are not using insurance an estimate of the bill for medical items and services.
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes (under the law/when applicable) related costs like medical tests, prescription drugs, equipment, and hospital fees.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. 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 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.
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 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.
This serves as my public disclosure of the “Good Faith Estimate”
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 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 800-985-3059. 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.
SURPRISE BILLING PROTECTION FORM
The purpose of this document is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care.
You can choose to get care from a provider or facility in your health plan’s network, which may cost you less.
This provider or facility isn’t in your health plan’s network. This means the provider or facility doesn’t have an agreement with your plan. Getting care from this provider or facility could cost you more. If your plan covers the item or service you’re getting, federal law protects you from higher bills:
•When you get emergency care from out-of-network providers and facilities, or
•When an out-of-network provider treats you at an in-network hospital or ambulatory surgical center without your knowledge or consent.
Ask your healthcare provider or patient advocate if you need help knowing if these protections apply to you.
Out-of-network provider(s) or facility name: Benavieri Counseling, LLC
Total cost estimate of what you may be asked to pay:
It is your ethical right to determine your goals for treatment and how long you would like to remain in therapy unless you are pursuing mandatory treatment.
Please see the breakdown of possible fees below.
►Review your detailed estimate.
►Call your health plan. Your plan may have better information about how much of these services are reimbursable.
►Questions about this notice and estimate? Call Benavieri Counseling and Coaching, 480-427-0122
►Questions about your rights? Contact: Arizona Board of Behavioral Health Examiners at 602-542-1882
Prior authorization or other care management limitations: Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval that it will cover an item or service before you get them. If prior authorization is required, ask your health plan about what information is necessary to get coverage.
More information about your rights and protections visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under federal law.
GOOD FAITH ESTIMATE SERVICES AND FEES
SAMPLE Diagnosis: F99.0 – Mental disorder, not otherwise specified
Out-of-network facility name: Benavieri Counseling, LLC
The amount below is only an estimate; it isn’t an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. It doesn’t include any information about what your health plan may cover. This means that the final cost of services may be different than this estimate.
Contact your health plan to find out how much, if any, your plan will pay and how much you may have to pay.
BREAKDOWN OF POSSIBLE FEES
90791: Individual or Couples Initial Intake Session – Initial Diagnostic Evaluation 60 minutes at $200
90832: Psychotherapy, 30 min at $90
90834: Psychotherapy, 45 min at $175
+99354: Prolonged service in the office/outpatient setting 30 minutes at $87.50
90846: Family Psychotherapy without Patient Present, 50 min at $175
90901: Biofeedback training, Neurofeedback 50 minutes at $200
99449: Interprofessional Telephone/Internet/Electronic Health Record Consultations including written report for the client’s file 30 minutes at $87.50
No Show/Late Cancellation Fee (Less than 24 hr notice) $175
Total Estimate: This Good Faith Estimate explains your therapist’s rate for each service provided. Your therapist will collaborate with you throughout your treatment to determine how many sessions and/or services you may need to receive the greatest benefit based on your diagnosis(es)/presenting clinical concerns.