Good Faith Estimate* THE NO SURPRISES ACT AND GOOD FAITH ESTIMATE HOW DOES IT AFFECT ME? WHY AM I BEING ASKED TO SIGN THIS? As of January 1, 2022, all healthcare providers are required to provide estimates for the costs of your care. The Good Faith Estimate (GFE) shows the cost of items and services that are reasonably expected for your healthcare needs and treatment. This will be provided by this office upon scheduling and/or as requested. This Good Faith Estimate does not include unexpected costs that could arise during treatment.
HOW DOES THIS AFFECT BILLING AND PAYMENT POLICIES AT Happy Health Nutrition LLC? The law protects you from surprise billing and “unexpected surprise charges”. Happy Health Nutrition LLC does not send patients a bill. You will pay for your sessions either 1) prior to the first session to serve as a confirmation or 2) charge the day of your session (policies and financial responsibility forms). WHAT IS THE ESTIMATE? DO I OWE THIS AMOUNT? Under provisions of this law, we are required to provide you with an estimate of your healthcare costs.You are entitled to receive this “Good Faith Estimate” of what the charges could be for nutrition services provided to you. While it is not possible for a therapist and/or dietitian to know, in advance, how many sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy and nutrition therapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of sessions with your dietitian. The number of visits that are appropriate in your case, and the estimated cost for those services will ultimately depend on your needs and what you agree to in consultation with your therapist and/or dietitian. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here. We ultimately value the importance of self-determination and the therapeutic relationship. It is important that you understand your right to choose your provider based on your unique needs, the provider’s specialization, and the right fit. DIAGNOSIS The No Surprises Act and Good Faith Estimate ask that we provide a diagnosis on this form. At New Hope Counseling and Wellness Center, LLC, we do not typically diagnose patients unless we believe a specific diagnosis to be accurate and after careful consideration, assessment, and after consultation with the patient. We are ethically obligated to only diagnose after a thorough evaluation, assessment, and discussion with you and/or your team. We reserve the right to defer diagnosis until we can properly assess your case, conduct an appropriate evaluation, and discuss treatment planning with you and your team. Therefore, the current diagnosis for the purpose of this document is not identified. CPT CODES CPT codes (Current Procedural Terminology) are used to identify the professional services they provide and to report those services in a way that can be universally understood by institutions, private and government payers, researchers, and others interested parties. Basically, this is a number that identifies the type of service received. Your treatment may include sessions that are coded by one or more of the CPT codes listed at the bottom of this form.
PROVIDERS HAppy Health Nutrition LLC provides therapy and nutrition services from dietitians. Our providers are listed below with their corresponding National Provider Identifier (NPI) and state licensure. The practice NPI and tax identification number (EIN) is listed at the top of the page. Providers at New Hope Counseling and Wellness Center with their corresponding NPI and licensure information are listed below. Provider: Lauren Budd Levy MS, RDN, CSR NPI: 1144996398 and EIN: 86-3377390
LOCATION OF SERVICES Happy Health Nutrition LLC is located at 9 Pine Ridge Drive Summit, NJ 07901. The providers listed conduct in virtual sessions. The estimate does not change based on your session being at the office or via telehealth.
EXPECTED FREQUENCY AND LENGTH OF TREATMENT We recognize that each patient has a unique treatment journey. Factors affecting your length of treatment may include: your presenting problem, history of presenting problem, stated goals for treatment, challenges and life circumstances, availability to schedule sessions, your support system, age at problem onset, presence of commonly occurring conditions we see in our patients, and others. Our standard practice is to create a treatment plan with patient input after the initial session (or we have time to develop treatment goals) and revise/update the treatment plan after six months. Therefore, we are providing this estimate based on the timeframe we use for treatment planning. The Good Faith Estimate is not a contract and therefore does not obligate you to receive the services listed below. Happy Health Nutrition LLC believes the therapeutic relationship to be paramount. We regard your autonomy, right to self-determination, and choice to receive treatment where you will most benefit.
DATE OF GOOD FAITH ESTIMATE The date of this GFE is the date in which you receive it through our portal. Understanding Your Good Faith Estimate (GFE) The following is a list of CPT codes that may be used. NOTE: The fee for each session is $180 per Initial session and 130 per follow up session. The CPT CODES We Most Commonly Use 97802: Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes, (this is billed in 15 minute increment. all sessions are four units at $50 per unit) 97803: Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes (this is billed in 15 minute increment. all sessions are four units at $50 per unit) This cost estimate is true regardless of the location (Office or Telehealth) and the CPT code used. You can determine your estimated healthcare costs by multiplying the session fee X the number of sessions that you anticipate seeing your provider. Additionally, you and your provider will discuss this as you review the treatment plan and will continue to review, revise, and update your plan as clinically indicated. NOTE: this estimate does not include healthcare cost associated with: Lab work or other tests that we may request Sessions with providers that are not listed on this form The cost to see a provider that we have recommended you to see and/or referred you to. The charge you may incur for no-show and/or late cancellations in accordance with our patient policies. The GFE is based on your estimated healthcare costs while receiving care at Happy Health Nutrition LLC with one of the providers listed on this form. Fees associated with emergency and/or crisis sessions Phone calls that proceed the length mentioned in the patient policies Documentation you may request Legal fees GFE: Diagnosis The following are common diagnosis used with our patients. If you would like a diagnosis added to your GFE please let a clinician know. NOTE: this list is not exhaustive, and we do utilize other diagnostic codes after consultation with you and your team. N18.2- Chronic kidney disease, stage 2 N18.31- Chronic kidney disease, stage 3a N18.32- Chronic kidney disease, stage 3b N18.4- Chronic kidney disease, stage 4 N18.5- Chronic kidney disease, stage 5 Other: GOOD FAITH ESTIMATE HEALTHCARE ITEMS AND SERVICES* Good Faith Estimate (GFE) You will be asked to sign this form. Your signature represents that you received this form, had the opportunity to discuss with your provider, understand your rights and that you understand how this relates to our practice. 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 803-569-9164.For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 803- 569-9164. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. If you want your diagnosis updated on this GFE after your assessment, you must let your clinician know.