Under Section 2799B-6 of the Public Health Service Act, you have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.
- Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service. 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 of picture of your Good Faith Estimate.
For questions or more information regarding your Good Faith Estimate, visit http://www.cms.gov/nosurprises or call 1-800-985-3059.
What are my rights?
- I am not obligated to receive services from Life Bridge Therapy or any out-of-network provider.
- I can cancel services at any time by notifying my provider 48 business hours before the scheduled service date.
- I have a right to initiate a dispute resolution process if the actual billed charges are substantially in excess of the expected charges included in this Good Faith Estimate.
- I may start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). I understand that the dispute process must begin within 120 calendar days from the date of the original bill.
- There is a $25 fee to use the dispute process. If the agency reviewing my dispute agrees with me, I will have to pay the price on the Good Faith Estimate If the agency disagrees with me, I will pay the higher amount.
- I can contact the No Surprises Help Desk at 1-800-985-3059 or visit http://www.cms.gov/nosurprises at any time to start the dispute process or to get more information.
What else Do I need to know?
- Life Bridge Therapy is in-network with Kaiser Permanente, Premera Blue Cross Blue Shield, and First Choice Health. However, it is important to note that some employer plans have third party payers in which the patient would need to check with their health insurance provider to make sure outpatient mental health services are covered as in-network.
- Information provided in a Good Faith Estimate is only an estimate of services reasonably expected to be furnished at the time the Estimate was provided. Actual items, services, or charges may differ from the Estimate.
- The Good Faith Estimate is not a contract.