GOOD FAITH ESTIMATE
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 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 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.
If you do not have insurance or choose not to use your insurance, Chase Chiropractic Center will provide a “Good Faith Estimate” (“GFE”) of how much our services will likely cost you upon request. If you are paying us directly for your services and you schedule at least 3 days in advance, we will provide a written GFE within 1 day of scheduling. If you schedule more than 3 days in advance, we will provide a written GFE within 3 business days after scheduling. To facilitate this we will send the GFE by e-mail if you provide an e-mail address.
We will inform you in advance with a new GFE if we plan to increase our fees or we anticipate your costs exceeding your original GFE. If we don’t and we bill you more than $400 in excess of your GFE without informing you in advance, you will have a right to dispute our bill through a federal dispute resolution process. You will need to provide a copy of your GFE to open a dispute, so we recommend that you save and/or print your GFE for future reference.
To request a GFE, please contact us at firstname.lastname@example.org or by phone (586)774-0091.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.
A Good Faith Estimate under this law is only applicable to uninsured individuals or individuals who choose not to bill their insurance and pay out of pocket.
A Good Faith Estimate is an ESTIMATE. It is not defining of what the actual charges may be.
A Good Faith Estimate is not a contract or "promise" to provide services for that estimated cost.
There may be additional services or items needed in the care of a patient that are not listed in the Good Faith Estimate. When those situations arise a separate GFE will be provided for those services or items and those charges will be above and beyond the existing GFE.
The patient always has the right to decline any services if the Good Faith Estimate is more than the patient might expect or choose to accept.
A person who has insurance but has not used it for the some of the period covered by the GFE, may choose later to start billing services to the insurance carrier. When this is done, the previously provided services under the GFE will not be billable to the insurance, but any further services after notification will be billed to the insurance. This choice also voids the GFE and any ability to dispute the charges through the No Surprises Act.
If the charges for the listed services within a Good Faith Estimate exceed the estimate by more than $400, the patient has the right to file a patient-provider dispute resolution process through the Federal Site listed above. If a patient initiates such a dispute, it will not interrupt the care nor create any change in the quality of care provided while the matter is being settled.
If there is a dispute the patient and provider can work together to find a resolution without resorting to the Federal resolution process.
If a patient has any unanswered questions about the Good Faith Estimate or any of the patient's rights under the No Surprises Act, we will be happy to discuss these and provide guidance to the Federal Resolution process.