No Surprise Act

"Good Faith Estimate"

If you are uninsured or not using insurance, healthcare providers are required by the No Surprises Act (effective January 1, 2022) to give you a Good Faith Estimate of your expected bill.

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Disclaimer:

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This Good Faith Estimate or "No Surprise Act" is the costs for your care and is not a contract. The total amount is based on information currently known at the time of the estimate given and is subject to change. It does not cover any unknown or unexpected costs that may arise during your treatment. If complications or special circumstances occur, you could be charged more.

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Understanding your Good Faith Estimate Rights and Options:

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During your care, your provider may suggest additional services or items not included in this estimate. These would require your approval and would be scheduled separately, with the understanding that their costs are not part of the original Good Faith Estimate.
Should your treatment needs change, your provider will issue a revised Good Faith Estimate to reflect any updates in services and costs.
If you notice that your bill is higher than the estimate, you can reach out to the provider or facility to request that the bill be adjusted to match the estimate, discuss possible negotiation, or inquire about financial assistance.

 

If your treatment plan changes, your provider will issue a revised Good Faith Estimate to reflect any updates in services and costs. Should you notice that your bill exceeds the amount listed in your estimate, you have the option to contact the provider or facility to request an adjustment to match the estimate, explore negotiation options, or inquire about available financial assistance.

 

Please be aware that the Good Faith Estimate is not a contract and it does not obligate you to receive any of the treatment services. You also have the right to initiate a dispute resolution process with the U.S. Department of Health and Human Services (HHS) if you believe you have been overcharged. If you receive a bill for the items or services listed in your Good Faith Estimate and the billed amount is $400 or more above the estimate, you may be eligible to initiate a dispute regarding the bill. This process allows you to formally challenge charges that significantly exceed your original estimate.

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Keeping Your Good Faith Estimate and Dispute Eligibility:

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It is important to store your Good Faith Estimate in a secure location so that you can reference it when reviewing any bills you receive for your care. By having the estimate readily available, you can easily compare the billed charges to the amounts originally provided.

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To initiate a dispute, you must start the process within 120 calendar days (approximately four months) from the date on your original bill. There is a $25 fee to use this process. If the reviewing agency finds in your favor, you will be responsible for paying the amount listed on the Good Faith Estimate; if the agency sides with the provider or facility, you will need to pay the higher amount.

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For further information or to obtain the necessary forms to begin the dispute process, visit www.cms.gov/nosurprises or call the U.S. Department of Health and Human Services (HHS) at (800) 985-3059.