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Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn't be charged more than your plan's copayments, coinsurance and/or deductible.

What is "balance billing" (sometimes called "surprise billing")?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional 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" means providers and facilities that haven't signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays 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 plan's deductible or 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. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You're protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most they can bill you is your plan's in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can't be balance billed for these emergency services. This includes services you may get after you're in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan's in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can't balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other types of services at these in-network facilities, out-of-network providers can't balance bill you, unless you give written consent and give up your protections.

You're never required to give up your protections from balance billing. You also aren't required to get out-of-network care. You can choose a provider or facility in your plan's network.

[Insert plain language summary of any applicable state balance billing laws or requirements OR state-developed language regarding applicable state law requirements as appropriate]

When balance billing isn't allowed, you also have these protections:

• You're only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.

• Generally, your health plan must:

o Cover emergency services without requiring you to get approval for services in advance (also known as "prior authorization").

o Cover emergency services by out-of-network providers.

o Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.

o Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you've been wrongly billed, contact [Insert contact information for entity responsible for enforcing the federal and/or state balance or surprise billing protection laws. The federal phone number for information and complaints is: 1-800-985-3059].

Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.

Notice: ​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 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 ​800-985-3059.

Reinventing Wellness Inc. Good Faith Estimate

Beginning January 1, 2022, federal laws regulating client care have been updated to include the "No Surprises" Act. Under the law, healthcare 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 called a "Good Faith Estimate" (GFE) explaining how much your medical care will cost.
This new regulation is designed to provide transparency to patients regarding their expected medical expenses and to protect them from surprises when they receive their medical bills. It allows patients to understand how much their health care will cost before they receive services.
There are a number of factors that make it challenging to provide an estimate on how long it will take for a client to complete therapeutic treatment, and much depends on the individual client and their goals in seeking therapy. Some clients are satisfied with a reduction in symptoms while others continue longer because it feels beneficial to do so. Others begin to schedule less frequently and may continue to come in for "check ins" or when issues arise using therapy as a tool throughout life. Ultimately, as the client, it is your decision when to stop therapy.

​At Reinventing Wellness Inc., we must provide a diagnosis for all clients for both ethical, legal, and insurance reasons -- as well as required by the "No Surprises Act". A formal diagnosis occurs after an assessment has been completed. That will take place 1-5 sessions after beginning psychotherapy. If you choose to decline a formal diagnosis, we will not update the GFE. It is within your rights to decline a diagnosis per state and federal guidelines.

​Common Diagnosis Codes at Reinventing Wellness Inc. This list is not exhaustive. Diagnosis codes can change. Please speak to your therapist with any questions or concerns.

• Adjustment Disorder (F43.23)
• Mental Disorder, Not Otherwise Specified (F99)
• Depression (F32.9)
• Anxiety (F41.1)
• PTSD/Post Traumatic Stress Disorder (F43.10)

​Reinventing Wellness Inc. recognizes every client's therapy journey is unique.
How long you engage in therapy and how often you attend sessions will be influenced by many factors including

• Your schedule and life circumstances
• Therapist availability
• Ongoing life challenges
• The nature of your specific challenges and how you address them
• Personal finances

You and your therapist will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for "graduation" and/or a new "Good Faith Estimate" will be issued should your frequency or needs change. Whatever your length of treatment, we will work together to meet your needs.

​Common Services at Reinventing Wellness Inc.

• 90791: Intake session ($200)
• 90847/46: Family/Couples psychotherapy session ($200)
• 90837: 53+ minute extended psychotherapy session ($200)

Where services will be delivered:

Virtual office in Nevada or Texas depending on client location

​Provider Information

• Provider Name: Reinventing Wellness Inc., Tamara Zenner, MS, LMFT, AAMFT Approved Supervisor
• License Numbers: NV 01377 TX 204476 
• NPI: 1932583887 TAX ID: 84-1776493

• Email: ZenTherapist.LMFT@gmail.com Phone #: 702-706-7119

Good Faith Estimate

​For a good faith estimate: the amount you would owe if you were to attend therapy for 52 sessions in a year (weekly, without skipping any weeks for holidays, break, vacation, unplanned events/sickness, etc.). The "Good Faith Estimate" requires practitioners to provide an exact estimate and not a range. Out of an abundance of caution and transparency, we will only quote weekly appointments.
90791: Intake session ($200) plus 90847/46: Family/Couples psychotherapy session ($200) for 51 weeks: $10,400
90791: Intake session ($200) plus 90837: 53+ minute psychotherapy session ($200): $10,400The above examples are provided to give an idea of the financial expectations for a calendar year. The frequency and duration is dependent on your individual needs and goals.
We look forward to talking with you and answering any questions you may have about the "No Surprises" Act and Good Faith Estimates.

​Good Faith Estimate Disclaimer

• This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.
• The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
• If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
• You may contact us at ZenTherapist.LMFT@gmail.com or call 702-706-7119 to let us know the billed charges are higher than the Good Faith Estimate. You can ask us to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
• 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 (about 4 months) of the date on the original bill.
• 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 or facility, you will have to pay the higher amount.
• To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

Please know that the Good Faith Estimate does not change any agreements you have already made with us with regard to self pay. Your review of this form and signature on your informed consent at intake is required so that we can demonstrate our compliance with the mandate. Thank you!