Good Faith Estimate
Seeking Shalom Marriage and Family Therapy, P.C. and Seeking Shalom Mental Health Counseling, P.C.
Midtown Manhattan (124 E 40th Street, New York, NY 10016) and West Bronx (2345 University Ave (at Fordham Rd), Bronx, NY 10468)
P.O. Box 8233, White Plains, NY 10602 (646)513-2866
This estimate would be with your information for the following.
Patient Name:
Patient Date of Birth:
Patient Mailing Address:
Patient Email Address:
Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to provide a good faith estimate of expected charges for items and services to individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage. This requirement begins in 2022 under the No Surprises Act.
At Seeking Shalom, we believe in transparency with our clients. Even before the federal government required these disclosures, we have been clear with our clients about the regular fees for their sessions and additional charges that they could be responsible for (as covered in the Client Information and Office Practices document each client receives). We also attempt to help clients answer the question that they are often really interested in, namely how much counseling or therapy will cost them out of their own pocket. This can be significantly different than full fees for a number of reasons such as if a client is in a discount program or has part or all of their fee being paid by a third party payer (like insurance).
Different aspects of health care are easier to predict what their course of treatment is likely to be. Generally, if you break your arm, the doctors have an idea of how many visits you are likely to need while it heals. Counseling and psychotherapy have a lot more variables involved and it can be difficult to predict the number of sessions that will be involved in your treatment. Additionally, clients often decide to work on additional areas than what they initially came in for, and there is no way to predict when that will occur. It is also not possible for us to know your full diagnosis and perhaps not even the way clinical sessions will be coded until after we have met with you and formulated a treatment plan. As a result, coming up with an estimate for the cost of your entire care is challenging and fraught with lots of problems if we are to provide you with an estimate the way the law requires.
The law only requires us to provide this form to some of our clients. We are electing to provide this form to all of our clients. We are doing this as there is always the possibility that even if you are in a group that would not be required to get this form that situations would occur that would move you into a situation where getting this form would be required. For example, if you are using your insurance to see an in network clinician but your insurance company decides that you are not covered, you would then be a client who is not using their insurance. As another example, it is possible that during your treatment you would become responsible for fees that are not covered by a third party payor and for those fees you would fall into the group of people who should get this form. In any case, we also feel that providing this to all our clients provides a certain degree of transparency.
This form is set up to give you a good faith estimate that is likely to overestimate the cost of your care over the next year. We are doing this in order to try and comply with the goal of no surprises. Your actual personal costs could be lower depending on the regular session fee you have (which depends on your clinician, the office you get care through, and any reduced fee program you are part of – please see the Client Information and Office Practices document for guidance on this – this estimate is based on the highest per session fees in the practice), your frequency of sessions (few clients will sustain twice weekly sessions which is the basis of this estimate) and the length of your treatment (this estimate is based on treatment extending over the full next year, but your treatment could end before a year has passed). This estimate is made in good faith not including any fees that are not session fees as these are not a normal part of treatment, but they are outlines in the Client Information and Office Practices document. These include: session reservation fee (for late cancellations and no shows), copying fees (when records are requested), external documentation fees (when third parties need to know about your treatment compliance), report writing fees (for reports going to outside parties), fees for testifying and appearances related to the client (if we have to go to court or hearings for you), technology fees (for some telehealth services), and emergency contacts fees (for crisis care). Even if you incur some of these added fees, their cost is likely to be less than the amount your actual costs are lower than the assumptions used around the base fees.
After we give you a good faith estimate, we will also provide you a way that you can estimate what your personal out of pocket costs are likely to be. If you want help creating that estimate, your clinician will also be willing to help you with such a possible estimate.
Formal Good Faith Estimate
This estimate is for the patient whose name, date of birth, identification number and contact information (mailing address, phone number and email address) is associated with the account within this form is placed.
The client will be receiving the following services:
- Evaluation – CPT code 90791
- Up to twice weekly therapy sessions – CPT code 90837 (any of the following CPT codes may be substituted and are billed at the same rate or less: 90834, 90832, 90876, 90847, 90853, 90849, 99404, 99403, 99402)
- The above CPT codes may be billed with modifiers and/or along with CPT codes 90785 and 96040
- The following additional CPT codes are not scheduled but could arise in the course of treatment: 90839, 90840, 99354, T1016, T1017, H0046, and 90899
These services have not been scheduled but will occur over the next twelve months.
The initial diagnostic impression of all clients is Z03.89 (a temporary code of “No Diagnosis”) or F99 (“Unspecified Mental Disorder” used when there is insufficient information to make a more specific diagnosis). An updated diagnostic impression is included on any treatment plan or invoice for a particular session, you may view these inside the client portal. Any variation in the patient diagnosis does not have an impact on the fees that we charge, although it may change the amount a third party payor is willing to pay.
These services will be provided by clinician(s) from Seeking Shalom Marriage and Family Therapy, P.C. and/or Seeking Shalom Mental Health Counseling, P.C. for an estimated total cost of $26,125.
The following is a detailed list of expected charges for treatment over the course of fifty-two weeks based on a maximal frequency of twice weekly sessions, not currently scheduled. The estimated costs are valid for 12 months from the date of the Good Faith Estimate.
Estimate
Facility Name: Seeking Shalom Marriage and Family Therapy, P.C. and/or Seeking Shalom Mental Health Counseling, P.C.
Facility Type: Private Practice (through professional corporations)
Facility Administrative Address: P.O. Box 8233, White Plains, NY 10602
Facility Clinical Address: Services will be provided at the office address for which sessions are booked through the client portal and may be in an office within New York City or by telehealth
Contact Person: Christopher L. Smith, LCAC, LMHC, LMFT
Contact Person’s Phone and Email: (212)655-9605 ClinicalDirector@SeekingShalom.org
National Provider Identifier:
- Seeking Shalom Marriage and Family Therapy, P.C. 1033493705
- Seeking Shalom Mental Health Counseling, P.C. 1043508567
- Each clinician involved in treatment – these are available at www.SeekingShalom.org
Taxpayer Identification Number:
- Seeking Shalom Marriage and Family Therapy, P.C. 45-3461947
- Seeking Shalom Mental Health Counseling, P.C. 45-2756729
Details of Services and Items
| Service | Address Where Service Provided | Diagnosis Code | Service Code | Quantity | Unit Cost ($) | Expected Cost ($) |
|---|---|---|---|---|---|---|
| Assessment | As scheduled | <1> | 90791 | 1 | 375 | 375 |
| Therapy | As scheduled | <1> | 90837* | 103 | 250 | 25,750 |
| Additional | As scheduled | <1> | <2> | 0 | Varies | 0 |
<1> Z03.89 or F99 or as updated in the records, but service cost independent of this
<2> 90839, 90840, 99354, T1016, T1017, H0046, and/or 90899
* or any substitute code of the same or lower cost (90834, 90832, 90876, 90847, 90853, 90849, 99404, 99403, and/or 99402) along with modifiers and/or add-on codes 90785 and 96040
Total expected charges from provider (and for all services and items): $26,125.
Disclaimer
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/consumers or call 1-800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059.
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.
Personal Calculation of Expected Personal Out of Pocket Costs
(not formally part of the Good Faith Estimate)
| Type of Clinician | Clinical Director | ||
| Licensed Clinician | |||
| Resident | |||
| Intern | |||
- Late cancel or no show fees: $35/75
- Copying Fees: vary but only if you want us to prepare and/or mail copies of your record
- External Documentation fees: $5-20, if simple, more if more complicated
- Report Writing Fees: varies depending on complexity, based on hourly rates
- Fees for Testifying and Appearances: more costly, but only if these become required
- Emergency Contacts fees: higher rates for more crisis calls, based on hourly rates
Expected Personal Out of Pocket Costs if Using Insurance
(not formally part of the Good Faith Estimate)
If you are using insurance (either in network with a provider that is in network with your insurance plan or out of network based on you submitting claims to your insurance company and that company agreeing to pay based on the clinician, services and diagnostic impression) calculations of your out of pocket costs are a little more tricky. They also rely on information you obtain from your insurance company about your plan and how they cover mental health care. We can give you some guidance, but the ultimate decision around these comes from your insurance company. Here are the costs that you can expect to have to meet:
If you are using out of network benefits, you will be responsible every session for the difference between your session fee (see previous example) and the UCR (“usual and customary rate” that may or may not have any relationship to real rates) the insurance company specifies the service you received.
For the rest of this explanation, we will use the term insurance rate to mean either the UCR (for those using out of network benefits) or the contracted rate (for those using in network benefits). This insurance rate also will not be more than your session fee (as seen in the previous example).
If you have a deductible in your insurance plan and the deductible applied to mental health care, you will be responsible for the full insurance rate for your session. The insurance rate for the session will reduce the amount of deductible you still have to pay towards future sessions. Also, if you get other healthcare it may reduce the amount of deductible you still have to meet.
Once you meet your deductible, you are likely to have to pay either a copay or coinsurance for each session. A copay is a fixed amount (like $25 or $60) that you pay for each session. In contrast, if you have to pay coinsurance, it is a percentage (like 20% or 50%) of the insurance rate for the session. Generally, copays and coinsurance are higher when using out of network benefits. Some health plans require you to pay both a copay and coinsurance. Your insurance company can best guide you about this.
Once you have reached an out of pocket maximum for the year (which counts some but not all of your expenses), then the insurance company will usually pay the full insurance rate and you will not be responsible for payments (except for the amount above UCR if you are out of network). This out of pocket maximum may be reached if you have a lot of other expensive medical procedures done during the year.