No Surprise Act & Good Faith Estimate
Starting January 1, 2022, medical providers, including mental health providers, must provide clients the following information related to out-of-network care:
Standard Notice and Consent Documents Under the No Surprises Act Surprise Billing Protection Form
CMS OMB Control Number: 0938-1401 This document describes your protections against unexpected medical bills. It also asks if you’d like to give up those protections and pay more for out-of-network care. IMPORTANT: You aren’t required to sign this form and shouldn’t sign it if you didn’t have a choice of health care provider before scheduling care. You can choose to get care from a provider or facility in your health plan’s network, which may cost you less. If you’d like assistance with this document, ask your provider. Take a picture and/or keep a copy of this form for your records. You’re getting this notice because this provider or facility isn’t in your health plan’s network and is considered out-of-network. This means the provider or facility doesn’t have an agreement with your plan to provide services. Getting care from this provider or facility will likely cost you more. If your plan covers the item or service you’re getting, federal law protects you from higher bills when: • You’re getting emergency care from an out-of-network provider or facility, or • An out-of-network provider is treating you at an in-network hospital or ambulatory surgical center without getting your consent to receive a higher bill. Ask your health care provider or patient advocate if you’re not sure if these protections apply to you. If you sign this form, be aware that you may pay more because: • You’re giving up your legal protections from higher bills. • You may owe the full costs billed for the items and services you get. • Your health plan might not count any of the amount you pay towards your deductible and out- of-pocket limit. Contact your health plan for more information. Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, you can also ask your health plan if they can work out an agreement with this provider or facility (or another one) to lower your costs. See the Good Faith Estimate for estimated fees.
Good Faith Estimate for Mental Health Services
Fees to be expected for each session/service:
Please be aware that fees are not always charged on the day of the session due to unexpected circumstances. Please be sure keep your own tally of what is owed and be prepared with the amounts owed to remain in your account until charged. Below is a link to our basic current fee chart on our website. These are per session/service: https://wholeheartcounselingservices.com/rates-insurance/
These fees are as follows: Regular session $125; No show/ late cancelation fee $75 Total fee if client chose to see an LPC counselor weekly for one year: $125 X 52 weeks = $6,500.00 per year. Every client’s needs are different, some clients see a counselor less often, some see a counselor for a shorter length of time, some more. Your needs are individual, and you are part of that decision.
Information on Diagnosis Codes:
WholeHeart Counseling Services, PLLC is out-of-network with all insurance companies and is therefore not required to use diagnosis codes for payment from them. All clients are self-pay; however, some clients may wish to file for out-of-network benefits with their insurance for reimbursement. If so, clients may request a receipt for services and a diagnosis code.
The new Good Faith Estimate law asks providers to diagnosis clients before they are seen. However, until we have met with you, it is commonly not seen as ethical to give a diagnosis, and so we are providing you some options below. As the list of actual possible diagnosis options are quite expansive, we also would like to provide you the website link to the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) site as well for your review: https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596
Commonly used Diagnosis Codes:
F41.1 – Generalized anxiety disorder F41.9 – Anxiety disorder, unspecified F41.0 – Panic disorder without agoraphobia F42.2 – Mixed obsessional thoughts and acts F43 – Adjustment disorders Z63.0 – Problems in relationship with spouse or partner F43.12 – Post-traumatic stress disorder, chronic F43.10 – Post-traumatic stress disorder, unspecified F34.1 – Dysthymic disorder F33 – Major depressive disorders F90.2 – Attention-deficit hyperactivity disorder, combined type F90.0 – Attention-deficit hyperactivity disorder, predominantly inattentive type F60.9 – Personality disorder, unspecified F84.0- Childhood autism
*If you have any questions about a diagnosis, please speak with your counselor.