No Surprises Act: Good Faith Estimate

1. Federal No Surprises Act — Overview

The No Surprises Act (NSA), enacted as part of the Consolidated Appropriations Act of 2021 and effective January 1, 2022, protects individuals from surprise medical billing in certain circumstances. Under regulations issued by the Centers for Medicare & Medicaid Services (CMS) at 45 CFR Part 149, the NSA requires healthcare providers and facilities to provide uninsured and self-pay patients with a Good Faith Estimate (GFE) of expected charges before services are rendered.

2. Your Right to a Good Faith Estimate

Under the law, health care providers must give patients who do not have insurance, or who are not using insurance, an estimate of the expected charges for medical services, including psychotherapy 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 one (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.

3. Standard CMS Disclaimer

You have the right to receive a Good Faith Estimate explaining how much your medical and mental health 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 one (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 1-800-985-3059.

4. When You Will Receive a Good Faith Estimate

Pasadena Clinical Group will provide a Good Faith Estimate to uninsured and self-pay patients:

• Upon request — you may ask for a GFE at any time before scheduling services
• At the time of scheduling — when you schedule an appointment as an uninsured or self-pay patient
• At least one (1) business day before scheduled services, if the appointment is scheduled at least three (3) business days in advance
• Within three (3) business days of your request, when the request is made at least three (3) business days before the scheduled service

The GFE will include the expected charges for the primary item or service (e.g., initial intake evaluation, individual therapy session, or per-session group therapy fee), and the expected charges for any other items or services that are reasonably expected to be provided in conjunction with the primary service.

5. Dispute Resolution Process

Under 45 CFR 149.620, if the total amount you are billed for services is substantially in excess (defined as at least $400 more) of the amount in your Good Faith Estimate, you have the right to initiate the Patient-Provider Dispute Resolution (PPDR) process. To initiate a dispute, you must submit a request to the U.S. Department of Health and Human Services (HHS) within one hundred twenty (120) calendar days of the date of the original bill. The PPDR process allows an independent dispute resolution entity to determine the appropriate payment amount. More information is available at the CMS No Surprises Act website.

6. Important Note

The No Surprises Act’s Good Faith Estimate requirement applies to patients who are uninsured (do not have health insurance) or who are self-pay (have insurance but choose not to use it for the services in question). If you are using health insurance to pay for services at Pasadena Clinical Group, the GFE provisions do not apply to you — instead, your insurance company will provide an Explanation of Benefits (EOB) detailing cost-sharing responsibilities. However, you are entitled to an estimate of any anticipated out-of-pocket costs from our billing department; please contact us for more information.

7. Informational Summary Only; Not Legal Advice

This page summarizes selected provisions of the federal No Surprises Act and related regulations for the convenience of patients of Pasadena Clinical Group. It is not legal advice, is not a complete recitation of the law, and may not address every fact pattern. The official text of the No Surprises Act, the implementing regulations at 45 CFR Part 149, and the guidance issued by the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS) control over any inconsistency with this summary. Nothing on this page is medical or mental-health advice, diagnosis, or treatment, and nothing on this page should be relied upon to self-diagnose or self-treat any condition. If you need legal advice about your specific situation, consult a qualified attorney; if you need medical or mental-health advice, consult a licensed provider.

8. Limitation of Liability; Released Parties

To the fullest extent permitted by law (and without diminishing any non-waivable obligation under the No Surprises Act, the federal Patient-Provider Dispute Resolution process, HIPAA, CMIA, the CCPA/CPRA, or other applicable law), Pasadena Clinical Group and each of its parent companies, subsidiaries, affiliates, owners, members, managers, partners, officers, directors, shareholders, supervising clinicians, employees, independent contractors, 1099 clinicians, supervisees, interns, post-doctoral fellows, externs, trainees, students, volunteers, peer-support workers, administrative staff, billing staff, vendors, agents, attorneys, accountants, insurers, indemnitors, successors, and assigns (collectively, the “Released Parties”) shall not be liable for any indirect, incidental, special, consequential, exemplary, or punitive damages arising out of or relating to any Good Faith Estimate, any disclosure required by this Notice, or any communication concerning patient billing. Nothing in this Notice waives a patient’s right to file a complaint with HHS or to pursue Patient-Provider Dispute Resolution. Each Released Party is an intended third-party beneficiary of this limitation of liability and is entitled to enforce it directly.

9. Mandatory Pre-Suit Notice, Mediation, and Binding Individual Arbitration

Without limiting any rights you have under the federal Patient-Provider Dispute Resolution process (which remains expressly preserved), and to the maximum extent permitted by California and federal law, any other dispute arising out of or relating to billing, charges, Good Faith Estimates, or this Notice shall be resolved by: first, written notice and sixty (60) days of good-faith negotiation; second, non-binding mediation administered by JAMS (or, by mutual agreement, by the AAA) in Los Angeles County, California; and third, if not resolved, final and binding individual arbitration administered by JAMS pursuant to the JAMS Comprehensive (or Streamlined) Arbitration Rules & Procedures and the JAMS Consumer Minimum Standards (or, by mutual agreement, by the AAA), in Los Angeles County, California, before a single neutral arbitrator, governed by the Federal Arbitration Act, 9 U.S.C. § 1 et seq., and the California Arbitration Act. The parties expressly waive any right to a jury trial and any right to participate in any class, collective, mass, consolidated, representative, or private-attorney-general action (other than as expressly preserved by non-waivable statute). Detailed dispute-resolution terms are set forth in our Terms & Conditions, incorporated by reference.

10. Contact Information

For questions about the No Surprises Act, Good Faith Estimates, or billing at Pasadena Clinical Group:

• Pasadena Clinical Group
• 301 N. Lake Ave, STE 600, Pasadena, CA 91101
• office@pasadenaclinicalgroup.com
• (626) 354-6440