No surprise act- Good Faith Estimate

We are required to provide you with information about the No Surprise Act - Good Faith Estimate

To learn more, go to www.cms.gov/nosurprises

• The No Surprises Act, which is part of the Consolidated Appropriations Act of 2021, is designed to protect clients from receiving unexpected medical bills. This is for patients who do not have insurance or who are not using insurance.

• The Good Faith Estimate provision of the No Surprises Act is designed to give clients an estimate of how much they’ll be charged for the healthcare services they’ll be receiving, prior to their appointment.

YOUR RIGHTS

You have the right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges). 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.
For questions or more information about your right to a Good Faith Estimate or the dispute resolution process, visit https://www.cms.gov/nosurprises/consumers or call 1- 800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you.