Your Right to a Good Faith Estimate

Overview

The No Surprises Act, which took effect January 1, 2022, was passed by Congress to protect patients from unexpected medical bills. Among its provisions, it requires all healthcare providers to offer uninsured and self-pay patients a written Good Faith Estimate (GFE) of expected costs before scheduled services are provided.

Who This Applies To

You are entitled to a Good Faith Estimate if you:

• Do not have health insurance, or
• Have health insurance but choose not to submit a claim to your insurance for the services

Please note that the Good Faith Estimate requirements under this notice do not apply to patients covered by Medicare, Medicaid, TRICARE, or other federal health programs, as those programs have separate cost protections. ANSA participates in Medicare and will work with you and your plan on Medicare-covered services.

What a Good Faith Estimate Includes

Before you receive services, ANSA will provide a written Good Faith Estimate that includes:

• Expected charges for the scheduled service or item
• A list of all items and services related to that visit that are reasonably expected to be provided
• Applicable diagnosis and service codes
• Name, address, and National Provider Identifier (NPI) of ANSA Neurology
• Any disclaimers regarding additional items or services that may need to be scheduled separately

The Good Faith Estimate is only an estimate. Actual charges may differ based on the specific services provided at your appointment.

How to Request an Estimate

You may request a Good Faith Estimate at any time, before or when scheduling a service. To request one:

• Call us at (818) 240-9041
• Email us at [email protected]
• Ask at the time of scheduling

If your service is scheduled at least three business days in advance, we are required to provide your GFE within one business day of scheduling. If scheduled at least ten business days in advance, the GFE must be provided within three business days.

If Your Bill Exceeds the Estimate

If you receive a bill that is at least $400 more than your Good Faith Estimate for any provider or facility, you may be able to dispute that bill through the Patient-Provider Dispute Resolution process.

For questions about your rights under the No Surprises Act or to learn more about the dispute resolution process, visit www.cms.gov/nosurprises or call 1-800-985-3059.

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