No Surprises Act

No Surprises Act (2022) Included in this document is demonstration of Grove Center for Therapy’s compliance with certain provisions of title I (the No Surprises Act) and title II (Transparency) of Division BB of the Consolidated Appropriations Act, 2021 (the CAA). PHS Act section 2799B–6, as added by section 112 of division BB of the CAA, requires providers and facilities, upon an individual’s scheduling of items or services, or upon request, to inquire if the individual is enrolled in a health plan or health insurance coverage, and to provide a notification of the good faith estimate of the expected charges for furnishing the scheduled item or service and any items or services reasonably expected to be provided in conjunction with those items and services, including those provided by another provider or facility, with the expected billing and diagnostic codes for these items and services. Good Faith Estimate (GFE) Service duration and frequency is provided primarily based on client request in partnership with clinical recommendation. Diagnostic assessments and individual, couples and family therapy sessions are generally scheduled for 50 minutes in duration. A common treatment protocol would include an initial intake appointment, one hour in length, during which a diagnostic assessment is completed. Sessions thereafter are normally 50 mins in duration occurring weekly, every other week or monthly as requested by client and per appropriate level of clinical response to client’s primary concern, symptom presentation and diagnosis. Shorter or longer length sessions may be appropriate for check-in/preventative appointments or for crisis concerns, respectively. Clients have the right to terminate services at any time for any reason. Beginning January 1, 2022, health care providers and facilities must provide a good-faith estimate of expected charges to uninsured consumers, or to insured consumers if they don’t plan to have their health plan help cover the costs (self-paying individuals). A good faith estimate (GFE) provided by Grove Center for Therapy shall include name and date of birth of individual seeking care services, description of primary service, itemized list of services reasonably expected to be rendered, service codes, an estimate of diagnosis, length of treatment and the cost associated with it, name of rendering provider(s) and facility, clinic location, tax ID and NPI numbers. This GFE shall be provided to all new clients who are seeking self-pay services. Additionally, a good faith estimate is available upon request at any time by any client. A request made in writing by a current or prospective client will be responded to within three (3) business days.

Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created, and does not include any unknown or unexpected costs that may arise during treatment.

Your rights

If you are billed for more than your Good Faith Estimate, you have the right to dispute the bill.

Throughout your treatment, the provider may recommend additional items or services as part of your treatment that are not reflected in this estimate. These would need to be scheduled separately with your consent and the understanding that any additional service costs are in addition to the Good Faith Estimate.

If your needs change during treatment, your provider should supply a new, updated Good Faith Estimate to reflect the changes to treatment, and the accompanying cost changes.

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.

The Good Faith Estimate is not a contract between provider and client and does not obligate or require the client to obtain any of the listed services from the provider.

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 HHS at (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 your Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.