Good Faith Estimate

Effective January 1, 2022, a ruling called the "No Surprises Act" requires practitioners to provide a "Good Faith Estimate" about out-of-network care. The Good Faith Estimate shows the cost of items and services that are reasonably expected for your health care needs for an item or service, a diagnosis, and a reason for treatment. The estimate is based on information known when 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 and will be provided a new "Good Faith Estimate" should this occur. If this happens, federal law allows you to dispute (appeal) the bill if you and your provider have not previously talked about the change and you have not been given an updated good faith estimate. 

Under Section 2799B-6 of the Public Health Service Act (PHSA), health care providers and health care facilities are required to inform 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 both orally and in writing of their ability, upon request, or at the time of scheduling health care items and services to receive a "Good Faith Estimate" of expected charges.

Note: The PHSA and GFE does not currently apply to any clients who are using insurance benefits, including "out of network benefits (i.e.., submitting superbills to insurance for reimbursement).

Common Services 

90792 - Psychiatric diagnostic evaluation with medical services

99204: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and a moderate level of medical decision making ( 45-59 minutes)

99205 - Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and a high level of medical decision making. (60-74 minutes)

90833: Psychotherapy, insight oriented, behavior modifying and/or supportive, 30 minutes with the patient and/or family member.

99214 - Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and a moderate level of medical decision making. When using time for code selection, 30-39 

99215: Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and a high level of medical decision making. (40-54 minutes)

Common Diagnosis Codes 

 Below are standard diagnosis codes at Labyrinth Behavioral Health; however, the list is not exhaustive. With that said, diagnosis codes can change based on many factors. Please speak to your provider with any questions or concerns.

• Adjustment Disorder (F43.23)

• Mental Disorder, Not Otherwise Specified (F99)

• Depression (F32.9)

• Anxiety (F41.1)

• Bipolar (F31.9)

• PTSD/Post Traumatic Stress Disorder (F43.10)

Every client's treatment journey is unique. 

How long you need to engage in treatment and how often you attend appointments will be influenced by many factors, including

• Providers availability

• Ongoing life challenges

• Your schedule and life circumstances

• The nature of your specific diagnosis and how often you need to be seen

• Medications you are prescribed, monitoring involved, and incremental increases

You and your provider will continually assess the appropriate frequency of appointments. You will work together to determine when you are progressing clinically and how often you need to be seen. 

Where services will be delivered. 

• We see patients in-office and using telehealth as such, all benefits will be quoted as virtual unless indicated otherwise in the notes section of this document. Patient Diagnosis
  At Labyrinth Behavioral Health, we must diagnose all clients for ethical, legal, and insurance reasons and are required by the "No Surprises Act." 

Your Good Faith Estimate diagnosis is:

Primary Diagnosis: F99 - Mental Health Disorder, Not Otherwise Specified.   This diagnosis is only to satisfy the federal requirement for this form. This is not a formal psychiatric diagnosis. A proper diagnosis occurs after an initial psychiatric assessment has been completed. That will take place at your first visit with your provider. If you decline a formal diagnosis, we will not update this GFE. It is within your rights to refuse a diagnosis per state and federal guidelines. 

Your Financial Responsibility Summary

For a good faith estimate: the amount you would owe if you were to come to the office for an initial new patient evaluation, weekly for four visits, bi-weekly x 3 visits, and then monthly for the remainder of the year. (without skipping any weeks for holidays, break, vacation, unplanned events/sickness, etc.). The "Good Faith Estimate" requires practitioners to provide an exact estimate and not a range.