Good Faith Estimate

1. What a Good Faith Estimate is

Under the No Surprises Act, health care providers must give patients who do not have insurance, or who are not using insurance, an estimate of the expected charges for medical items and services.

It is an estimate made in good faith on the information available at the time. It is not a bill, and it is not a contract or an obligation for you to go ahead with the care described.

2. Who it is for

• Anyone who does not have health insurance.
• Anyone who has insurance but is choosing not to use it for this care, often called self-pay.

If you are using insurance, this notice does not apply. Your health plan will tell you what it covers and what your share is, and the practice will tell you what it can before you book.

3. What the estimate contains

• Your name and date of birth.
• A plain description of the care, such as an initial psychiatric evaluation or a follow-up appointment.
• The service and diagnosis codes that apply, with the expected charge for each.
• The provider's details and the location where care would be given.
• Items or services reasonably expected to be provided together with the care, and a note of anything that would need to be scheduled and estimated separately.

4. When you should receive one

• Whenever you ask for one, in writing, within three business days.
• If care is scheduled at least three business days ahead, within one business day of scheduling.
• If care is scheduled at least ten business days ahead, within three business days of scheduling.

You should also be told, orally and in writing, that you can ask for an estimate before scheduling anything.

5. If your bill is higher than the estimate

If you are billed at least 400 dollars more than your Good Faith Estimate, you may be able to dispute the bill through the patient and provider dispute resolution process run by the United States Department of Health and Human Services.

• You must start the dispute within 120 calendar days of the date on the bill.
• There is a small administrative fee to use the process.
• Starting a dispute will not affect the quality of care you receive.

Information about your rights and about the dispute process is available from the Centers for Medicare and Medicaid Services. Ask the practice and you will be pointed to the current guidance.

6. How to ask for an estimate

Call (720) 897-6735 or email info@hawthornepsychiatry.com and ask for a Good Faith Estimate. You do not need to give a reason, and asking does not commit you to booking anything.

Keep a copy of the estimate you are given, and keep a copy of any bill that follows it.