Good Faith Estimate
Effective January 1, 2022, a ruling went into effect called the “No Surprises Act” which requires licensed clinicians provider 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 an item or 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 at Women’s Wellness Center Of Virginia, LLC
90791: Diagnostic Assessment (60 min) $175 90834: Individual therapy session (45 minutes) $135 90837: Individual therapy session (60 minutes) $150
Sliding Scale through Open Path ($ 60 per session)
Common Diagnosis Codes at Women’s Wellness Center of Virginia, LLC
Below are common diagnosis codes at Women’s Wellness Center of Virginia. however, the list is not exhaustive. With that said, diagnosis codes can change based on many factors. Please speak to your provider with any questions or concerns.
- Postpartum Depression (F53.0)
- Adjustment Disorder (F43.23)
- Depression (F32.9)
- Anxiety (F41.1)
- Bipolar Disorder (F31.9)
- Posttraumatic Stress Disorder (F43.10)
Women’s Wellness Center 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
- Clinicians availability
- Ongoing life challenges and or changes
- 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.
Where Services Will Be Delivered:
Women’s Wellness Center offers only virtual services to individuals physically located in the states of Virginia and Florida at the time of services. Services take place over a HIPAA compliant telehealth platform Simple Practice.
At Women’s Wellness Center we must provide a diagnosis to all patients for ethical, and legal, as well as required by the “No Surprises Act”.
Your initial Good Faith Estimate diagnosis is: Postpartum Depression (F53.0) This diagnosis is only to satisfy the federal requirement for this form. This is not a formal psychological diagnosis. A formal diagnosis occurs after an assessment has been completed. It is within your rights to decline a diagnosis per state and federal guidelines.
Your Financial Responsibility Summary
For a good faith estimate, we are providing the amount you would owe if you were to attend psychotherapy for 52 sessions in a year (weekly, without skipping any weeks for holidays, break, vacation, unplanned events/sickness, etc. The “Good Faith Estimate” requires providers to provide an exact estimate and not a range. Out of an abundance of caution and transparency, this quote is based on higher frequency of appointments, though your actual frequency could be more or less, depending on your unique mental health needs.
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 an item or service. 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 (appeal) the bill. 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.