Good Faith Estimate, GFE

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 GFE for the total expected cost of any non0emergency items or services. This includes related costs like medical test, prescriptions drugs, equipment and clinical or hospital fees.
Make sure your health provider gives you a GFE in writing 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 GFE, you can dispute your bill.
Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a GFE visit, www.cms.gov/nosurprises or call 18009853059

Sample:

Dr. Justin Trosclair, DC (Patient’s House or Business) House Call Chiropractic, NPI 1528268612 presents a Good Faith Estimate (GFE)
We charge $155 for a new patient exam and treatment and $90 for follow-up treatments ($125 for scoliosis treatments) at the time of service performed. The office can give you a superbill that has codes for services performed with a cost that you can submit to your health insurance company as out of network benefits. All plans are different so you may have a deductible that must be paid before the health insurance company pays anything and/or a copay.
You understand that you may receive $0.00 reimbursed by the health insurance company and you are agreeing to pay the amounts listed above.
Codes and fees charged could be 1 or many of any of the below codes and can be submitted to the health insurance company but this office only charges the $155 or $90 ($125 scoliosis). Travel fees range from $5-25 per visit above the aforementioned charges and are an additional charge.

99202 new patient exam 20 minutes $95, 99203 new patient exam 30-44 minutes $95, 99211 re-exam est 10 min $60, 99212 re-exam est 15min $60, 98940 (CMT); spinal, one or two regions $60, 98941 (CMT); spinal, three or four regions $60, 98943 extremity $30, 97110 therapeutic exercises $30, 97112 neuromuscular reeducation $30, 97140 manuel therapy $30, S9090 spinal decompression $30, s8948 cold laser $30, kinesiology taping $30.

Disclaimers:

  • There may be additional items or services the convening provider or convening facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate.
  • The information provided in the good faith estimate is only an estimate regarding items or services reasonably expected to be furnished at the time the good faith estimate is issued to the uninsured (or self-pay) individual and that actual items, services, or charges may differ from the good faith estimate.
  • Individual’s right to initiate the PPDR process if the actual billed charges are substantially in excess of the expected charges included in the good faith estimate (over $400). Initiation of the PPDR process will not adversely affect the quality of health care services furnished to the individual by a provider or facility. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurpirses or call (1-800-985-3059).
  • The good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the good faith estimate

I have read and understand this agreement.