NO SURPRISE BILLING ACT INFORMATION

Good Faith Estimate

You have the Right to Receive a Good Faith Estimate of Expected Charges Under the No Surprises Act. If you are choosing to use out-of-network benefits this information is included in an introductory email from Introspect Mental Health. If you would like to receive your Good Faith Estimate in paper form, please contact our main line and or let your provider know.

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

Under the law, healthcare 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 healthcare 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 healthcare 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 our main line at (763) 465-6700.

OUR GENERAL FEES FOR SERVICES

Code 90791: Diagnostic Assessment $250.00

Code 90832: 30 Minutes Session $150.00

Code 90834: 45 Minutes Session $175.00

Code 90837: 53 Minutes Session $200.00

Code 90847: Family Session $200.00

Late Cancel- Less than 24 hour notice/ No Call/ No Show: $100.00

DEFINITIONS

“Balance Billing” When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a healthcare facility that isn’t in your health plan’s network. 

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit. 

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. 

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network. 

You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

Your health plan generally must:

Cover emergency services without requiring you to get approval for services in advance (prior authorization).

Cover emergency services by out-of-network providers.

Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits

Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact Leah directly or reach information for consumers at https://www.cms.gov/nosurprises/consumers.