Good Faith Estimate
Under the No Surprises Act
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 one 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 Emily Keller at (925) 290-0036.
Your therapeutic journey will be influenced by multiple factors including scheduling challenges, life circumstances, therapist availability, diagnoses, personal finances, and other outside events, such as a global pandemic, that may alter the current treatment schedule.
Common Psychotherapy Services
- 90791: Intake session ($180)
- 90834: 45-50 minute psychotherapy session ($180)
- 90847/46: Family/Couples psychotherapy session ($180)
- 90837: 90-minute extended psychotherapy session ($315)
- 90853: Group therapy session ($100)
Add-On CPT Code 90785. Interactive complexity. Example: play therapy using dolls or other toys.Add-On CPT Code 99354. For extended session.
Therefore, a sample GFE estimate will indicate, for example, that if you receive weekly 50-minute psychotherapy for the duration of one year, you will be billed for a total of $9,360 (52 x $180). Most clients have one visit per week. Occasionally, some clients will have two.
- 381 Earhart Way, Livermore, CA, 94550
- Online in CA and NC only.
- Provider Name: Emily Keller, LLC; NPI: –; TAX ID: –; Email: firstname.lastname@example.org; Phone (925) 290-0036
Dr. Keller will offer you a Good Faith Estimate at the beginning of our work together. The GFE will be assigned as a form through the Counsol.com gateway. Please review and ask any questions. Your signature is required so that we can demonstrate our compliance with the federal mandate. Thank you!
Want to explore calculating a Good Faith Estimate or making changes to your treatment? Use the calculator below: