Good Faith Estimate

Effective January 1, 2022, a ruling went into effect called the "No Surprises Act," which requires practitioners to provide a "Good Faith Estimate" to individuals who are uninsured or utilize self-pay. The Good Faith Estimate (referred to throughout this document as “GFE”) works to show the cost of items and services that are reasonably expected for your health care needs for an item or service, a diagnosis, and a reason for mental health services. The estimate is based on information known at the time the estimate was created.

The GFE does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur and you will be provided with a new GFE should this occur. If this happens, federal law allows you to dispute (appeal) the bill if you and your provider have not previously talked about the change and you have not been given an updated GFE.

Under Section 2799B-6 of the Public Health Service Act (PHSA), 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 GFE of expected charges.

Note: The PHSA and GFE do not currently apply to any individuals who are using insurance benefits, including out-of-network benefits (i.e., submitting superbills to insurance for reimbursement).

No Surprises Act

Providers are required to provide a GFE of expected charges for a scheduled or requested service, including items or services that are reasonably expected to be provided in conjunction with such scheduled or requested item or service. That estimate must be provided within specified time frames:

• If the service is scheduled at least 3 business days before the appointment date: no later than 1 business day after the date of scheduling;

• If the service is scheduled at least 10 business days before the appointment date: no later than 3 business days after the date of scheduling; or

• If the uninsured or self-pay individual requests a GFE (without scheduling the service), no later than 3 business days after the date of the request. A new GFE must be provided, within the specified time frames if the individual reschedules the requested item or service.

Below are common service codes used at this practice; however, the list is not exhaustive.

• 90791: Initial psychotherapy assessment

• 90832: Ongoing therapy session (16-37 min.)

• 90834: Ongoing therapy session (38-52 minutes)

• 90837: Ongoing therapy session (53-60 minutes)

• 90853: Group psychotherapy (60 minutes)

Below are common diagnosis codes that are given to clients at this practice; however, the list is not exhaustive and diagnosis codes can change based on many factors. Please discuss any questions or concerns you may have with your provider.

• Adjustment Disorder (F43.23)

• Mental Disorder, Not Otherwise Specified (F99)

• Depression (F32.9)

• Anxiety (F41.1)

• Bipolar Disorder (F31.9)

• Posttraumatic Stress Disorder (F43.10)

We recognize that every individual’s mental health treatment journey is unique and personalized. How long you need to engage in mental health services and how often you attend sessions will be influenced by many factors, including, but not limited to:

• Your schedule and life circumstances

• Your provider’s availability

• Ongoing life challenges

• The nature of your specific challenges and how you address them

• Personal finances

You and your provider will continually assess the appropriate frequency of services and will work together to determine when you have met your goals and are ready for discharge, and/or a new "Good Faith Estimate" will be issued should your frequency or needs change.

Common Diagnosis Codes

Common Service Codes

Timeline Requirements

Additional Information

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