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 are entitled to receive a “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here.
The Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.
If you attend therapy for a longer period, your total estimated charges will increase according to the number of visits and length of treatment.
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 the 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/or get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 368-1019. 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) 368-1019.
Always keep a copy of the Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount. You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in the Good Faith Estimate.
- 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 (877)696-6775, or call the BFCW front desk at (719)644-6131.
You are entitled to receive a “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here.
The Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.
If you attend therapy for a longer period, your total estimated charges will increase according to the number of visits and length of treatment.
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 the 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/or get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 368-1019. 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) 368-1019.
Always keep a copy of the Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount. You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in the Good Faith Estimate.
Surprise/Balance Billing
Federal laws protects you* from “surprise billing,” also known as “balance billing.”
These protections apply when:
• You receive covered emergency services, other than ambulance services, from an out-of-network provider and/or
• You unintentionally receive covered services from an out-of-network provider at an in-network facility in Colorado/Nevada
What is surprise/balance billing, and when does it happen?: If you are seen by a health care provider or use services in a facility or agency that is not in your health insurance plan’s provider network, sometimes referred to as “out-of-network,” you may receive a bill for additional costs associated with that care. Out-of-network health care providers often bill you for the difference between what your insurer decides is the eligible charge and what the out-of-network provider bills as the total charge. This is called “surprise” or “balance” billing.
When you CANNOT be balance-billed:
Emergency Services
If you are receiving emergency services, the most you can be billed for is your plan’s in-network cost-sharing amounts, which are copayments, deductibles, and/or coinsurance. You cannot be balance-billed for any other amount. This includes both the emergency facility where you receive emergency services and any providers that see you for emergency care.
Nonemergency Services at an In-Network or Out-of-Network Health Care Provider
The health care provider must tell you if you are at an out-of-network location or at an in-network location that is using out-of-network providers. They must also tell you what types of services that you will be using may be provided by an out-of-network provider.
You have the right to request those in-network providers perform all covered medical services. However, you may have to receive medical services from an out-of-network provider if an in-network provider is not available. In this case, the most you can be billed for covered services is your in-network cost-sharing amount, which are copayments, deductibles, and/or coinsurance. These providers cannot balance bill you for additional costs.
Additional Protections
• Your insurer will pay out-of-network providers and facilities directly.
• Your insurer must count any amount you pay for emergency services or certain out-of-network services (described above) toward your in-network deductible and out-of-pocket limit.
• Your provider, facility, hospital, or agency must refund any amount you overpay within sixty days of being notified.
• No one, including a provider, hospital, or insurer can ask you to limit or give up these rights.
If you receive services from an out-of-network provider or facility or agency OTHER situation, you may still be balance billed, or you may be responsible for the entire bill. If you intentionally receive non-emergency services from an out-of-network provider or facility, you may also be balance billed.
Nevada: DPBH at (702) 668-3250 or https://dpbh.nv.gov/Reg/HealthFacilities/dta/Complaints/HCQC-Complaint-Form/
If you think you have received a bill for amounts other than your copayments, deductible, and/or coinsurance, please contact the billing department or:
Colorado Division of Insurance at 303-894-7490 or 1-800-930-3745
Nevada Division of Insurance at https://doi.nv.gov/Consumers/File-A-Complaint/
Federal Phone Number: (800) 985-3059
*This law does NOT apply to ALL Colorado health plans. It only applies if you have a “CO-DOI” on your health insurance ID card.*
These protections apply when:
• You receive covered emergency services, other than ambulance services, from an out-of-network provider and/or
• You unintentionally receive covered services from an out-of-network provider at an in-network facility in Colorado/Nevada
What is surprise/balance billing, and when does it happen?: If you are seen by a health care provider or use services in a facility or agency that is not in your health insurance plan’s provider network, sometimes referred to as “out-of-network,” you may receive a bill for additional costs associated with that care. Out-of-network health care providers often bill you for the difference between what your insurer decides is the eligible charge and what the out-of-network provider bills as the total charge. This is called “surprise” or “balance” billing.
When you CANNOT be balance-billed:
Emergency Services
If you are receiving emergency services, the most you can be billed for is your plan’s in-network cost-sharing amounts, which are copayments, deductibles, and/or coinsurance. You cannot be balance-billed for any other amount. This includes both the emergency facility where you receive emergency services and any providers that see you for emergency care.
Nonemergency Services at an In-Network or Out-of-Network Health Care Provider
The health care provider must tell you if you are at an out-of-network location or at an in-network location that is using out-of-network providers. They must also tell you what types of services that you will be using may be provided by an out-of-network provider.
You have the right to request those in-network providers perform all covered medical services. However, you may have to receive medical services from an out-of-network provider if an in-network provider is not available. In this case, the most you can be billed for covered services is your in-network cost-sharing amount, which are copayments, deductibles, and/or coinsurance. These providers cannot balance bill you for additional costs.
Additional Protections
• Your insurer will pay out-of-network providers and facilities directly.
• Your insurer must count any amount you pay for emergency services or certain out-of-network services (described above) toward your in-network deductible and out-of-pocket limit.
• Your provider, facility, hospital, or agency must refund any amount you overpay within sixty days of being notified.
• No one, including a provider, hospital, or insurer can ask you to limit or give up these rights.
If you receive services from an out-of-network provider or facility or agency OTHER situation, you may still be balance billed, or you may be responsible for the entire bill. If you intentionally receive non-emergency services from an out-of-network provider or facility, you may also be balance billed.
Nevada: DPBH at (702) 668-3250 or https://dpbh.nv.gov/Reg/HealthFacilities/dta/Complaints/HCQC-Complaint-Form/
If you think you have received a bill for amounts other than your copayments, deductible, and/or coinsurance, please contact the billing department or:
Colorado Division of Insurance at 303-894-7490 or 1-800-930-3745
Nevada Division of Insurance at https://doi.nv.gov/Consumers/File-A-Complaint/
Federal Phone Number: (800) 985-3059
*This law does NOT apply to ALL Colorado health plans. It only applies if you have a “CO-DOI” on your health insurance ID card.*
We DO NOT have administrative support on site, at any of our locations. For additional support:
Our phone lines are monitored Monday - Thursday, from 9am-1pm MST: (866) 644-6131
If no one answers, we are on the other line. Please leave a message and we will call you back or email us at
[email protected]
For General Inquiries: Please click here.
Our phone lines are monitored Monday - Thursday, from 9am-1pm MST: (866) 644-6131
If no one answers, we are on the other line. Please leave a message and we will call you back or email us at
[email protected]
For General Inquiries: Please click here.
Locations
|
Barnes Rd., Colorado Springs, CO
4775 Barnes Rd. Ste L Colorado Springs, CO 80917 |
Briargate Blvd., Colorado Springs, CO
3475 Briargate Blvd. Ste 201 Colorado Springs, CO 80920 |
Las Vegas, NV
Teleheath Only |
Phone: (866) 644-6131
Fax: (719) 434-9615
[email protected]
If you or someone you know is in crisis, call 911, go to the nearest emergency room, or call 1-800-273-TALK (8255) to reach a 24-hour crisis center.
You matter and you are never alone.
Barber Family Counseling and Wellness is proud to support our military members, veterans and dependents.
Fax: (719) 434-9615
[email protected]
If you or someone you know is in crisis, call 911, go to the nearest emergency room, or call 1-800-273-TALK (8255) to reach a 24-hour crisis center.
You matter and you are never alone.
Barber Family Counseling and Wellness is proud to support our military members, veterans and dependents.