You have the right to receive a Good Faith Estimate of the expected charges for medical or psychological services from Pasadena Clinical Group. This page explains what that means and how to request one.
1. Your Right to a Good Faith Estimate Under the No Surprises Act
Under Section 2799B-6 of the federal Public Health Service Act (the "No Surprises Act," effective January 1, 2022), health-care providers and facilities must give patients who do not have insurance, or who are not using insurance to pay for care, a written estimate of the expected charges for medical and mental-health services. Pasadena Clinical Group, as a California outpatient psychology practice, complies with this requirement.
You also have the right to receive a Good Faith Estimate when you choose to use insurance for some services and self-pay for others, or when you choose to pay out of pocket for any reason.
2. What a Good Faith Estimate Includes
The Good Faith Estimate ("GFE") we provide will include:
- The patient's name and date of birth
- The provider's name, National Provider Identifier (NPI), and Tax Identification Number (TIN), as applicable
- A description of the primary item or service (for example: individual psychotherapy, group psychotherapy, diagnostic intake)
- The applicable Current Procedural Terminology (CPT) or other service codes
- The expected charge per session
- An expected number of sessions or frequency over a specified period (typically twelve months for ongoing outpatient psychotherapy)
- The expected total estimated cost over that period
- A disclaimer that actual costs may differ depending on the actual course of care
- Notice of your right to dispute a final bill that is at least $400 more than the estimated charges, and the federal patient-provider dispute resolution process
3. When You Will Receive a Good Faith Estimate
You will receive a written GFE before your first appointment, generally:
- Within one (1) business day of scheduling, if you schedule the service less than ten (10) business days in advance
- Within three (3) business days of scheduling, if you schedule the service ten (10) or more business days in advance
- Within three (3) business days of any request for a GFE, even if you have not yet scheduled an appointment
4. The Estimate Is Not a Binding Bill
Psychological treatment is collaborative and may change over time as your needs and goals change. The GFE reflects the expected, not guaranteed, cost of services based on typical courses of treatment for similar presentations. Your actual costs may be higher or lower depending on:
- The actual number of sessions you attend
- Changes in the type of service (for example, transitioning between individual and group)
- Additional services that are clinically indicated and not anticipated at intake
- Changes in our standard rates
If we determine the expected scope of services has materially changed, we will provide an updated GFE.
5. Your Right to Dispute a Final Bill
If you receive a final bill from Pasadena Clinical Group that is at least four hundred dollars ($400) more than your most recent GFE for the same service, you have the right to initiate a patient-provider dispute resolution (PPDR) process administered by the U.S. Department of Health and Human Services. Key features of the PPDR process include:
- You generally must initiate the dispute within one hundred twenty (120) days of receiving the bill.
- You will be required to pay an administrative fee, which may be reduced or waived for low-income individuals.
- A certified independent dispute-resolution entity (IDRE) will review the bill and the GFE and issue a determination.
- The determination is binding except where it is overturned through a federal review.
- Throughout the dispute process, the provider may not move the disputed bill to collections or threaten to do so.
Detailed information and forms are available at www.cms.gov/nosurprises or by calling 1-800-985-3059.
6. Surprise Billing Protections
The No Surprises Act also provides protections against unexpected out-of-network charges in certain settings. If you receive emergency services or services from an out-of-network provider at an in-network facility, federal law generally limits your cost-sharing to in-network amounts and protects you from balance billing for the difference. As an outpatient psychology practice, we do not generally provide emergency-room services; nevertheless, we follow these protections wherever they apply.
7. California State Protections
Under California law (including AB 72), additional protections apply to insured Californians who receive non-emergency services at in-network facilities from out-of-network providers. If you have questions specific to California protections, please contact our care coordinator or the California Department of Managed Health Care.
8. Insured Clients
If you use insurance to pay for services, you will receive your insurer's Explanation of Benefits (EOB) or Advance Explanation of Benefits (AEOB) per their standard practice. Your in-network cost-sharing (copay, coinsurance, and any unmet deductible) will be discussed at intake.
9. Self-Pay Rates
Our self-pay rates and payment options will be discussed during your intake conversation. We can also discuss limited sliding-scale availability where applicable.
10. How to Request a Good Faith Estimate
You may request a Good Faith Estimate at any time. Please contact our care coordinator:
Pasadena Clinical Group
301 N. Lake Ave, STE 600
Pasadena, CA 91101
Phone: 626-354-6440
Email: office@pasadenaclinicalgroup.com
11. Save Your Good Faith Estimate
Please keep a copy or photo of any GFE we send you. You may need it if a dispute arises and you wish to invoke your federal dispute-resolution rights.
12. Updates and Effective Date
This notice may be updated from time to time. The current version is available at www.pasadenaclinicalgroup.com/good-faith-estimate.html and is effective as of the date listed at the top of this page.
13. More Information
For more information about your rights under federal law, visit www.cms.gov/nosurprises or call 1-800-985-3059. For California-specific questions, visit www.dmhc.ca.gov.