You have the right to receive a Good Faith Estimate explaining the cost of your medical care.
Under the No Surprises Act (45 CFR 149.610), health care providers are required to give patients who do not have insurance — or who choose not to use their insurance — an estimate of the bill for medical items and services. This is called a Good Faith Estimate ("GFE").
The following statement is the standard CMS notice required by federal law:
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 bill for medical items and services.
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.
How we provide your GFE.
If you are uninsured or choose to self-pay, we will provide a written Good Faith Estimate before your first session. The estimate will include:
- The expected services (e.g., a 50-minute individual therapy session, a 90-minute couples session).
- The fee for each service.
- An estimate of the total cost over an expected course of care, based on the clinical assessment.
- The diagnosis code and procedure code (CPT) where applicable.
- Disclaimers required by federal law.
The actual cost may differ from the estimate based on the actual services provided. The estimate is not a contract; you are not required to obtain the estimated services.
Disputing a bill.
If your final bill is $400 or more above the GFE for any single item or service, you may initiate a Patient-Provider Dispute Resolution process under 45 CFR 149.620. The process is administered by an entity selected by the U.S. Department of Health and Human Services. Information on initiating dispute resolution is available at www.cms.gov/nosurprises or by calling 1-800-985-3059.
For insured clients.
If you are using insurance, the No Surprises Act protections related to surprise out-of-network charges and uninsured GFE requirements may not apply in the same way. Your Explanation of Benefits ("EOB") from your insurer is the authoritative document for what your plan paid and what you owe. Our billing team will help you understand your EOB and work with you on any balance.
Selecting providers.
You have the right to select the provider of your choice. We are happy to help you understand whether PCG is a good fit clinically and financially. If we are not the right provider for your situation, we will help you identify alternatives.
Contact billing.
For questions about your Good Faith Estimate or any billing matter, please contact our billing team at (626) 354-6440 or office@pasadenaclinicalgroup.com.