Good Faith Estimate

Your Right to a Good Faith Estimate Under the No Surprises Act

Blooming Arc Psychiatric Care PLLC

Your Right to a Good Faith Estimate

You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost.

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 psychiatric and mental health care.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

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 can dispute the bill.

Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.

1. What the No Surprises Act Requires

The No Surprises Act took effect January 1, 2022. Under Section 2799B-6 of the Public Health Service Act and its implementing regulations at 45 C.F.R. § 149.610, health care providers and facilities are required to give a Good Faith Estimate of expected charges to individuals who are uninsured or who are self-pay.

A Good Faith Estimate is a notification of expected charges for a scheduled or requested item or service. It is based on information reasonably available to us at the time we create the estimate.

2. Who Is Entitled to a Good Faith Estimate

You are entitled to a Good Faith Estimate from our practice if you are:

  • Uninsured — you have no health insurance coverage; or

  • Self-pay — you have health insurance coverage but you do not intend for us to submit a claim to your health plan for the item or service.

Because our practice is currently completing insurance credentialing, most of our patients are self-pay. If that applies to you, you will receive a Good Faith Estimate as a matter of course — you do not have to ask for it.

If you are using insurance benefits, the Good Faith Estimate requirement does not apply to you. Instead, contact your health plan for an Advanced Explanation of Benefits and information about your deductible, copayment, and coinsurance.

3. When You Will Receive Your Good Faith Estimate

We will provide your Good Faith Estimate in writing, in the following timeframes:

Situation When you will receive your estimate You schedule an appointment at least 3 business days in advance Within 1 business day of scheduling You schedule an appointment at least 10 business days in advance Within 3 business days of scheduling You request an estimate without scheduling Within 3 business days of your request

If the expected charges change after we issue your estimate — for example, because the scope of your evaluation changes — we will provide you with a new Good Faith Estimate no later than 1 business day before the scheduled service.

Requesting a Good Faith Estimate does not obligate you to schedule an appointment or to receive care from our practice.

4. What Your Good Faith Estimate Will Include

Your written Good Faith Estimate will contain the information required by federal law, including:

  • Your name and date of birth

  • A plain-language description of the primary item or service

  • An itemized list of the items and services we reasonably expect to provide

  • The applicable diagnosis codes, service codes, and expected charges for each item or service

  • The name, National Provider Identifier (NPI), and Tax Identification Number (TIN) of our practice, and the state where services will be provided

  • A list of items or services that require separate scheduling and are expected to occur before or following the scheduled service

  • A disclaimer explaining your right to initiate the patient-provider dispute resolution process

  • A disclaimer that the estimate is only an estimate and that actual charges may differ

5. Ongoing and Recurring Care

Psychiatric care is often ongoing. When your care involves recurring appointments — such as regular medication management follow-ups or psychotherapy sessions — your Good Faith Estimate may cover recurring items and services.

Under federal regulations, a Good Faith Estimate for recurring care may not cover a period longer than 12 months. If your care continues beyond that period, we will provide you with a new Good Faith Estimate and give you the opportunity to review it.

The estimate will clearly state the expected scope of recurring care, including the expected number of appointments, their frequency, and the expected duration of treatment.

6. What Is Not Included in Your Estimate

A Good Faith Estimate from our practice covers only the items and services we expect to provide directly. It does not include charges from other providers or facilities you may see as part of your care, such as:

  • Laboratory testing ordered as part of your treatment

  • Pharmacy costs for prescribed medications

  • Psychological or neuropsychological testing performed by another provider

  • Emergency room, hospital, or higher-level-of-care services

  • Services from a separate therapist, primary care physician, or specialist

You have the right to request a separate Good Faith Estimate from each of those providers.

7. Your Right to Dispute a Bill

If you are billed for an amount that is at least $400 more than the total expected charges on your Good Faith Estimate, you have the right to dispute the bill.

You may start a patient-provider dispute resolution process with the U.S. Department of Health and Human Services. Key points:

  • You must start the dispute process within 120 calendar days of the date on your bill.

  • There is a $25 administrative fee to use the dispute process.

  • If the dispute resolution entity agrees with you, you will pay the price on the Good Faith Estimate.

  • If the dispute resolution entity agrees with our practice, you will pay the billed amount.

  • We may not move the bill into collections or threaten collections while the dispute is being reviewed.

  • We may not retaliate against you in any way for disputing a bill. You will not be refused care, and your care will not be provided in a less timely manner, because you initiated a dispute.

To learn more about the dispute process or to start a dispute, visit www.cms.gov/nosurprises or call 1-800-985-3059.

8. Important Limitations of a Good Faith Estimate

Please understand the following:

  • A Good Faith Estimate is an estimate, not a bill, a contract, or a guarantee of final cost. It reflects what we reasonably expect based on the information available when it was prepared.

  • Your actual charges may differ if your clinical needs change, if additional services become medically necessary, or if the length or complexity of your appointment changes.

  • A Good Faith Estimate does not obligate you to receive care from our practice.

  • A Good Faith Estimate does not include any fees unrelated to the delivery of care, such as fees for late cancellation or missed appointments. Those terms are set out separately in your intake paperwork.

  • If you later decide to use insurance for a service that was estimated as self-pay, the Good Faith Estimate no longer applies. Contact your health plan for your coverage details.

9. How to Request a Good Faith Estimate

You may request a Good Faith Estimate at any time, before or after scheduling, and at no cost.

To request an estimate, contact us:

Blooming Arc Psychiatric Care PLLC Suite #1182 7055 Old Katy Rd Houston, TX 77024

Phone: (346) 826-9197 Fax: (346) 724-3404 Email: diweni@bloomingarc.com Website: bloomingarcpsychiatry.com

We will confirm your request and provide your written estimate within the timeframes described in Section 3. Your estimate will be delivered through our secure patient portal or, at your request, by mail or in paper form at your appointment.

If you have questions about cost, please ask. We would rather talk about it openly before your first appointment than have you carry that uncertainty into the room.

10. Emergencies

The No Surprises Act protections described here apply to non-emergency services. If you are experiencing a psychiatric emergency, call 911, call or text 988 (Suicide & Crisis Lifeline), or go to your nearest emergency room.

This page is provided in accordance with the No Surprises Act, Section 2799B-6 of the Public Health Service Act, and 45 C.F.R. § 149.610. It is informational and does not constitute legal advice.

This page is provided in accordance with the No Surprises Act, Section 2799B-6 of the Public Health Service Act, and 45 C.F.R. § 149.610. It is informational and does not constitute legal advice.