YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE
(OMB Control Number: 0938-1401)
Tandem Counseling, LLC
5734 N Broadway Street, Kansas City, MO 64118
Tandem Counseling LLC provides the Good Faith Estimate document to all patients in accordance with the No Surprises Act. The Good Faith Estimate (GFE) shows the cost 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 (GFE) does not include any unknown or unexpected costs that might arise during treatment. These types of costs from your provider will be discussed prior to being charged, and you are given an option to proceed or seek alternative options.
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care - like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Costs that arise outside of the providers control (I.e emergency services or hospitalization/assessment) cannot be known at the time of the GFE; and a GFE will be given by that separate health care provider. If a new GFE needs to be given after treatment begins, this will be discussed and agreed on between you and your provider.
A diagnosis is required for the Good Faith Estimate (GFE). This should be discussed with your provider as they may not have all details necessary for a formal diagnosis, at the time the GFE is provided. And if a diagnosis is to be changed or requested at a later time, the document will be updated and agreed upon with the patient. Furthermore, since this office does not accept insurance, no diagnosis will be released without your express written consent.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you unless you give written consent and give up your protections.
You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
If a complication or special circumstance occurs and you were charged something that was not in the agreement, Federal Law allows you to dispute the bill. You may contact the health care provider or facility to let them know the billed charges are higher than the Good Faith Estimate or not verbally agreed on prior to the charge. 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.
When balance billing isn’t allowed, you also have the following protections:
You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
Your health plan generally must:
Cover emergency services without requiring you to get approval for services in advance (prior authorization).
Cover emergency services by out-of-network providers.
Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact Missouri Division of Professional Registration, 3605 Missouri Boulevard, P.O. Box 1335, Jefferson City, MO 65102-1335 or by phone at
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 of the original bill. According to their process 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 the 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.
Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 368-1019.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019.
You will receive a copy of the Good Faith Estimate from your provider. Keep a copy of the Good Faith Estimate in a safe place, download a copy (if electronic) or take a picture of it. You may need it if you are billed a higher amount.