No Surprises Act / Good Faith Estimate

This page describes your rights under the federal No Surprises Act (Public Law 116-260, Division BB, Title I; codified at 42 U.S.C. §300gg-131 et seq. and 45 C.F.R. §§149.610, 149.620), as implemented by the Centers for Medicare & Medicaid Services ("CMS"), and the corresponding obligations of Pasadena Clinical Group ("the Practice"). The information on this page is published for educational purposes and does not, by itself, create or replace any contract for services. The controlling document is the Good Faith Estimate ("GFE") your clinician provides at intake.

You have the right to receive a Good Faith Estimate

"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."

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.
• Make sure your healthcare provider gives you a Good Faith Estimate in writing at least one (1) business day before your medical service or item. You can also ask your healthcare 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 1-800-985-3059.

1. Who is entitled to a GFE

You are entitled to a written GFE if (a) you are uninsured or (b) you are insured but choose not to use your insurance ("self-pay") for the items or services. If you are using insurance for our services, the GFE process described here generally does not apply; your estimate of out-of-pocket costs is determined through your insurer's coverage documents. The Practice may, on request, provide a benefits estimate as a courtesy.

2. What the GFE includes

Your GFE will include, consistent with 45 C.F.R. §149.610(c):

• The patient's name and date of birth;
• An itemized list of items or services reasonably expected to be furnished — for example, intake evaluation, individual or group therapy sessions, family or couple sessions, treatment-plan review;
• Applicable diagnosis (ICD-10) and procedure (CPT) codes;
• The expected charge for each item or service;
• The name, NPI, and TIN of each provider expected to furnish items or services;
• The service location;
• The period to which the estimate applies (typically the initial twelve (12) weeks of care, after which the estimate is reviewed and reissued, or earlier on material change);
• The required disclaimer language and notice of dispute rights.

3. How and when we provide your GFE

If you are uninsured or self-pay, the Practice will provide a written GFE:

• Within one (1) business day of scheduling, if the service is scheduled at least three (3) business days in advance;
• Within three (3) business days of scheduling, if the service is scheduled at least ten (10) business days in advance; or
• Within three (3) business days of your written request for a GFE.

The GFE will be provided in writing — on paper or, with your consent, electronically — and in a manner that you can save or print. The Practice may also discuss the GFE with you at intake and answer any questions about it.

4. What is not included

The GFE covers the items and services reasonably expected at the time of issuance. It typically does not include items or services that arise later in the work, such as: additional psychological testing; psychiatric medication consultation by an outside provider; emergency referral; intensive-outpatient or residential transition; legal/forensic services; report writing for third parties; record copying beyond statutory amounts; missed-appointment fees; or court-related fees. If a new item or service is recommended that materially changes the estimate, the Practice will issue an updated GFE before the new item or service is provided. Items furnished by other providers (e.g., independently retained psychiatrists) are not included; you may request a separate GFE from each.

5. Estimates are estimates — not a guarantee

A Good Faith Estimate is an estimate, not a guarantee, contract, or fixed price. Actual charges may differ based on the actual services rendered, the duration of care, intensity of treatment, missed sessions, or unforeseen circumstances. The estimate does not bind your insurer, if any, to any coverage determination. The estimate also does not commit you or the Practice to a particular course of treatment.

6. Patient-Provider Dispute Resolution ("PPDR")

If you receive a bill from the Practice that is at least $400 more than the most recent GFE for the items or services billed, you may initiate the federal patient-provider dispute resolution process administered by CMS. Key elements (45 C.F.R. §149.620):

• Deadline: initiate within 120 calendar days of receiving the bill.
• How to file: through the CMS-administered process described at cms.gov/nosurprises/help-resolve-payment-disputes/patient-provider or by calling 1-800-985-3059. An administrative fee of $25 generally applies and is refundable if the resolution is in your favor.
• Selected Dispute Resolution Entity: CMS will assign a Selected Dispute Resolution Entity ("SDR Entity") that will review the materials and issue a binding determination.
• Stay on collection: while a dispute is pending, the Practice will not move the disputed amount into collections, charge interest on the disputed amount, or take other adverse action.
• Cooperation: the Practice will provide the SDR Entity with the GFE, billing records, and any other information requested.

The PPDR process applies to the federal $400 threshold. Use of the PPDR process does not waive your other rights under California or federal consumer-protection law, but is, where applicable, the preferred avenue for billing disputes covered by the No Surprises Act.

7. California protections; Knox-Keene

California law also protects healthcare consumers in various ways, including the Knox-Keene Health Care Service Plan Act (Cal. Health & Safety Code §1340 et seq.), the Insurance Code, and AB 72 (codified at Cal. Health & Safety Code §1371.9 et seq.) for surprise out-of-network bills in some settings. The Practice does not provide emergency services and is not subject to the same surprise-billing scenarios as facility-based emergency providers, but we comply with applicable California consumer-protection laws and refer disputes to the appropriate state agency where applicable.

8. Translation, accommodations, and accessibility

You have the right to receive your GFE in a language you can understand and in an accessible format. The Practice can provide language assistance and reasonable accommodations on request, consistent with Section 1557 of the Affordable Care Act (42 U.S.C. §18116) and the Americans with Disabilities Act (42 U.S.C. §12101 et seq.).

9. Questions, complaints, and no retaliation

You may direct questions about the GFE process to our Privacy Officer (below) or to CMS at 1-800-985-3059. If you believe the Practice has not complied with the No Surprises Act, you may file a complaint with CMS at the same number or at cms.gov/nosurprises. The Practice will not retaliate against you for asserting your rights under this law.

10. Dispute resolution under the Practice's Terms

Use of the federal PPDR process does not displace, but operates alongside, the dispute-resolution provisions of the Practice's Terms & Conditions, which require mandatory mediation, then binding individual arbitration in Los Angeles County, California, with class-action and jury waivers, except to the extent inconsistent with non-waivable consumer protections under California or federal law (including the No Surprises Act).

Contact us about this page

Questions, requests, or complaints regarding this page or your Good Faith Estimate can be directed to our Privacy Officer, Pasadena Clinical Group, 301 N. Lake Ave, STE 600, Pasadena, CA 91101, by phone at (626) 354-6440, or by email at office@pasadenaclinicalgroup.com.