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No Surprise act Disclosures

Good Faith Estimate Cost of Services

 

Under Section 2799B-7 of the Public Health Service Act and its implementing regulations, the U.S. Department of Health & Human Services (HHS) is required to establish a patient- provider dispute resolution process where a Selected Dispute Resolution (SDR) entity can resolve a payment dispute between individuals who are not enrolled in a group health plan, or group or individual health insurance coverage, or a Federal health care program, or a Federal Employees Health Benefits (FEHB) program health benefits plan (uninsured individuals), or who are not seeking to file a claim with their group health plan, health insurance coverage, or FEHB health benefits plan (self-pay individuals), and health care provider, facility, or provider of air ambulance services by determining the amount such individual must pay to their health care provider, facility, or provider of air ambulance services. Under federal criteria, SDR entities will review initiation notices to determine that an uninsured (or self- pay) individual is eligible to dispute a bill.

Section 45 CFR 149.610(c), establishes requirements for the content that must be included in a good faith estimate that is issued to an uninsured (or self-pay) individual. Per 45 CFR 149.610(c)(1), all of the required elements must be included in the good faith estimate that the convening provider or convening facility issues to the uninsured (or self-pay) individual. As specified in 45 CFR 149.610(c)(1)(iii)(B), the good faith estimate information submitted by co- providers or co-facilities, as specified in 45 CFR 149.610(b)(2) and (c)(2) must also be included as part of the good faith estimate issued to the uninsured (or self-pay) individual. 

 

Facility Information: Kristin Lulich, Advanced Practice Registered Nursing Inc./DBA Mind Bloom La Jolla

1120 Silverado Street Suite 203, La Jolla, CA 92037

TIN: 83-2006063 

Facility NPI 1659912723 

 

Service Codes/Description of Services/Expected charges by Providers:

Kristin Lulich, DNP, PMHNP-BC 

Katherine Lais, DNP, PMHNP-BC

Kirsten Kuhn, MSN, PMHNP-BC

Adrian Davis, MSN, PMHNP-BC

Simone Borghei, MSN, PMHNP-BC

Separate good faith estimates will be issued to an uninsured (or self-pay) individual upon scheduling of the listed items and services 

90792- Psychiatric Diagnostic Evaluation with Medical Services (Initial evaluation with Psychiatric Nurse Practitioner 60 minutes)

-Estimated Charge $350 

99214 Evaluation and management of established patient 

-Estimated Charge $175 

 

 

Mary Weiss, M.D. 

Separate good faith estimates will be issued to an uninsured (or self-pay) individual upon scheduling of the listed items and services 

90792- Psychiatric Diagnostic Evaluation with Medical Services (Initial evaluation with Psychiatrist) 60 minutes

-Estimated Charge $400

99214 Evaluation and management of established patient

-Estimated Charge $200

 

Erin Grimes, PsyD

Separate good faith estimates will be issued to an uninsured (or self-pay) individual upon scheduling of the listed items and services 

90791- Psychiatric Diagnostic Evaluation without Medical Services (Initial evaluation with Psychologist/Therapist)

-Estimated Charge $165

90837-Psychotherapy 50-60 minutes

-Estimated Charge $150

-96132- Neuropsychological testing/evaluation/results interpretation 

-Estimated Charge $150

 

Dana Speroni, Executive Functioning Coach- Fees for Executive Functioning Coaching are based on time of session

Separate good faith estimates will be issued to an uninsured (or self-pay) individual upon scheduling of the listed items and services 

0591T- Health and Well-Being Coaching Initial assessment (60 Minute service)

-Estimated Charge $125 

0592T-Health and Well-being Coaching (30 minutes)

-Estimated Charge $62.50 

0592T-Health and Well-being Coaching (20 Minutes)

-Estimated Charge $41.67 

0592T- Health and Well-being Coaching (10 Minutes) 

-Estimated Charge $20.83

 

Required Disclaimers:

Following an initial evaluation (90792, 90791, 0591T) for continued services, separate sessions may be recommended or required for continued follow up care/treatment (99214, 90837, 0592T) separate good faith estimates are required to be provided upon scheduling services

Estimates Subject to Change: The information provided in the good faith estimate are estimates and not the final overall total charges.

Additional Items/Services not included in Good Faith Estimate: Additional items and/or services that are not in the good faith estimate may be recommended by the convening provider as part of the course of care, that must be scheduled separately and are not reflected in the good faith estimate (such as Transcranial Magnetic Stimulation, Spravato, among others) In the event these services are considered a separate Good Faith Estimate will be provided.

Right to initiate patient-provider dispute resolution process: In the case of any errors in billing/if your believe there has been an overcharge you have the right to initiate the patient-provider dispute resolution process if the actual billed charges from any provider or facility are $400 more than the expected charges from that provider or facility included in the good faith estimate.

Please contact our billing department with any questions/concerns about billing, we are happy to correct any inaccuracies or explain any charges

This Good Faith Estimate is not a contract: A good faith estimate is not a contract and does not require the uninsured (or self- pay) individual to obtain the items and services from any of the providers or facilities identified on the good faith estimate.

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