GOOD FAITH ESTIMATE

YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE
 MEDICAL BILLS
(OMB Control Number: 0938-1401)

You are protected from “balance billing” when:

You get emergency care or treatment from an out-of-network provider at an in-network hospital or ambulatory surgical center. Then you are protected from surprise billing or balance billing.


What is “balance billing”?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care – like when you have an emergency or when you schedule a visit at an in-network facility, but are unexpectedly treated by an out-of-network provider.


If Hope Springs is not in-network with your insurance, and you want in-network coverage, you can choose a provider or facility in your plan’s network.

If you want in-network rates, and we are not in-network for your insurance, you will likely be referred to a different office or clinic than Hope Springs, as we do not accept every insurance at our office.

If you are seen at Hope Springs, and are out of network, we will use balance balance billing. It will follow the fee schedule included in our outpatient service contract.


Additionally, beginning January 1, 2022, health care providers are required to estimate the cost of services for patients self-paying or not using their insurance because the provider is out of network for their benefits.

We will provide a detailed list of expected charges for your services.

It is likely that your provider will over-estimate the cost of services to provide you with the maximum expected out of pocket cost for treatment.

This estimate is based on information known at the time the estimate was created. If additional services are recommended, a new estimate will be presented to you for your signature.

Estimated costs are valid for 12 months after the date of the Good Faith Estimate. The Good Faith Estimate is not a contract, and signing it does not obligate you to obtain the services estimated. Please talk with your provider about the estimate if you have questions or concerns.

The Good Faith Estimate is an estimate and may not include any unknown or unexpected costs that may arise during treatment. Therefore, actual items, services and charges may differ from the Good Faith Estimate. If this happens, federal law allows you to dispute (appeal) the bill.

If you are billed more than the Good Faith Estimate, you have rights.

  • You may contact the health care provider listed to let them know the billed charges differ from the Good Faith Estimate. You can ask the provider to have the bill reflect the Good Faith Estimate, ask to negotiate the bill, or ask if financial assistance is available.
  • The Good Faith Estimate is an estimate and may not include any unknown or unexpected costs that may arise during treatment. Therefore, actual items, services and charges may differ from the Good Faith Estimate. If this happens, federal law allows you to dispute (appeal) the bill.
  • You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days of the date on the original bill. You can learn more about how to start this process, or to learn more about Good Faith Estimates, at www.cms.gov/nosurprises or call HHS. A patient-provider dispute resolution process initiation will not affect the quality of health care services provided.
  • There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider, you will have to pay the higher amount.
  • Please keep a copy of your Good Faith Estimate for your records.

The No Surprises Law has already seen several revisions, so it is subject to change. This document on the CMS website actually has an expiration date of 3/31/22.