Good Faith Estimate
According to the Good Faith Estimate provision within the No Surprises Act, health care providers and facilities, as of January 1, 2022, must provide a Good Faith Estimate of expected charges upon request. This law pertains to patients who do not have insurance or are not using insurance (private pay). For additional information on Good Faith Estimates, read the disclaimer posted under the chart.
Therapy after Surgery
*Your actual visits may vary from the above numbers based on your severity and/or complexity. Appointments are typically 20-40 minutes in length.
OMB Control Number 0938-XXXX
Expiration Date 01/01/2023
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 the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them 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 1-877-696-6775.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-877-696-6775.
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.
Most insurance carriers discount for the prices below and pay according to your plan design - your co-pay/deductible/co-insurance is based on your plan design.
|Treatment/CPT Code||Billed as a single unit:||Medicare Reimbursement:|
|Moderate PT Evalutation/97162 (visit 1)||$212||$94.35|
|Cash-Based Programs||$50||At time of service|
*Insurance/Billing questions or concerns, contact us at OTbillingdept@optimumtherapies.com or 701-751-3064; and check with your insurance carrier.