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Federal No Surprises Act Notice

Good Faith Estimate

This Good Faith Estimate notice applies to Mathew Brigante, PhD, New York State Licensed Psychologist, License No. 026659, doing business as Brigante Psychology (hereinafter, “the Practice”).

Under the federal No Surprises Act and 45 C.F.R. § 149.610, an uninsured or self-pay individual has the right to receive a Good Faith Estimate of expected charges for scheduled or requested health-care items and services.

For this rule, “uninsured or self-pay” includes a person who does not have applicable health coverage for the item or service and a person who has coverage but does not seek to have a claim for the item or service submitted to that coverage.

Official sources: 45 C.F.R. § 149.610 ↗ · CMS — Good Faith Estimate rights ↗

When the Estimate Must Be Provided

  • If a primary item or service is scheduled 3 through 9 business days before the service date, the Good Faith Estimate must be provided no later than 1 business day after scheduling.
  • If a primary item or service is scheduled 10 or more business days before the service date, the Good Faith Estimate must be provided no later than 3 business days after scheduling.
  • If an uninsured or self-pay individual requests a Good Faith Estimate, the estimate must be provided no later than 3 business days after the request.

A discussion or inquiry about the potential cost of services is treated as a request for a Good Faith Estimate under the federal rule.

Official sources: 45 C.F.R. § 149.610(b)(1)(iii)–(vi) ↗

What an Individualized Good Faith Estimate Contains

An individualized Good Faith Estimate must be written in clear and understandable language and must contain the information required by 45 C.F.R. § 149.610(c), including the patient information, expected items or services, applicable codes and expected charges, and required provider-identification information.

  • Patient name and date of birth.
  • A clear description of the primary item or service and, when applicable, the scheduled date.
  • An itemized list of items or services reasonably expected during the period of care.
  • Applicable diagnosis codes, expected service codes, and expected charges.
  • The name, National Provider Identifier, Tax Identification Number, and service location information required by the federal rule for providers represented in the estimate.
  • The federally required statements explaining that the estimate is based on information reasonably known when issued, that actual services or charges may differ, that additional separately scheduled services may not be included, that the estimate is not a contract, and how to use the patient-provider dispute-resolution process.

The public website notice is not itself an individualized Good Faith Estimate and therefore does not publish patient-specific information, an NPI, or a Tax Identification Number.

Official sources: 45 C.F.R. § 149.610(c) ↗

Recurring Psychotherapy Services

A single Good Faith Estimate may cover recurring primary services when it clearly states the expected scope of the recurring services, including the applicable timeframe, frequency, and total number of expected recurring services. A recurring-services estimate may not cover a period longer than 12 months. If additional recurring services are expected beyond that period, a new Good Faith Estimate must be provided.

Official sources: 45 C.F.R. § 149.610(b)(1)(x) ↗

Changes to an Estimate

If the Practice anticipates a change in the scope of a previously issued Good Faith Estimate for a scheduled service, federal law requires a new Good Faith Estimate no later than 1 business day before the affected item or service is scheduled to be furnished.

Official sources: 45 C.F.R. § 149.610(b)(1)(vii) ↗

If the Bill Is $400 or More Above the Estimate

If the billed charges from a particular provider or facility are at least $400 more than the amount shown for that provider or facility on the Good Faith Estimate, you may be eligible for the federal patient-provider dispute-resolution process. The dispute generally must be initiated within 120 calendar days of the date on the initial bill.

Initiating the federal patient-provider dispute-resolution process may not adversely affect the quality of health-care services furnished to an uninsured or self-pay individual.

CMS — Dispute a medical bill ↗

Official sources: CMS — Patient-Provider Dispute Resolution ↗ · 45 C.F.R. § 149.620 ↗

How to Request a Good Faith Estimate

Submit a request through the secure SimplePractice prospective-client inquiry form available from the Home page. A request concerning the potential cost of services will be treated as a Good Faith Estimate request as required by federal law.

Ordinary email and telephone are not accepted as channels for psychotherapy inquiries, scheduling, referrals, clinical advice, risk assessment, crisis services, or emergency assistance.

The individualized Good Faith Estimate will be provided in written form, on paper or electronically according to the requested method of delivery, and an electronic estimate will be provided in a form that can be saved and printed, as required by federal law.

Official sources: 45 C.F.R. § 149.610(e) ↗ · CMS — Required Good Faith Estimate Notice ↗