No Surprises Act: Good Faith Estimate
"No Surprises Act" 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 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 will be provided 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).
Timeline requirements: 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 timeframes:
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 timeframes if the individual reschedules the requested item or service.
Common Services Provided by Mindful Therapeutic Practices/Costs For Services
Billing Codes & Fees
90791: Initial Psychotherapy intake (not timed)……………………………………………..$160.00
90837: Ongoing therapy appointments (approx.. 53-60 minutes)………………….$140.00
90847: Family/Couples appointments (approx.. 45-60 minutes)…………………….$140.00
90834: Ongoing therapy appointments (approx. 38-45 minutes)…………………...$105.00
90832: Ongoing therapy appointments (approx.. 16-35 minutes)…………………..$70.00
Common Diagnoses Used
Below are common diagnosis codes at Mindful Therapeutic Practices; however, the list is not exhaustive. With that said, diagnosis codes can change based on many factors. Please speak to your practitioner with any questions or concerns.
Adjustment Disorder (F43.23)
Mood Disorder Not Otherwise Specified (F39)
Major Depressive Disorder (F33.--)
Generalized Anxiety Disorder (F41.1)
Bipolar Disorder (F31.--)
Post-traumatic Stress Disorder (F43.10)
Mindful Therapeutic Practices recognizes 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.
Good Faith Estimate Disclaimer
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for behavioral-mental healthcare treatment. The estimate is based on information known at the time the estimate was created.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute the bill. You may also be billed for late cancels, no shows, administrative time and paperwork related to your individual needs (letter writing, disability paperwork, legal matters, etc.) as you signed in the Consent/Contract for Services.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. 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.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
Group NPI: 1538566799
Group EIN: 472395682