NO SURPRISES ACT / GOOD FAITH ESTIMATE

You have the right to receive a “Good Faith Estimate” explaining
how much your medical and mental health care will cost.

Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.
• You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a 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.
• 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 health care 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 may start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose 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 services. If the agency reviewing your dispute agrees with you, you will have to pay the price on the Good Faith Estimate provided to you. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
• The Good Faith Estimate does NOT include any unknown or unexpected costs that may arise during treatment. There may be additional items or services that are recommended as part of your mental health care services that must be scheduled or requested separately and, therefore, may not be reflected in the Good Faith Estimate. **Any additional services provided and billed for will be discussed with you in advance by your clinician at Candeo.
• **It is recommended you first contact your clinician at Candeo to let make them aware that your bill 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. The initiation of the dispute resolution process will not adversely affect the quality of health care services provided 

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (800) 368-1019.