The information provided is a Good Faith Estimate and does not include any unknown or unexpected costs that may arise during treatment. This estimate will be based on the information you have provided and the most current benefits available from your insurance company. Benefits and eligibility are subject to change and are not a guarantee of payment. Final billed charges may vary for many reasons, among them are the patient’s medical condition, unknown circumstances or complications, final diagnosis and recommended treatment ordered by the physician.
In addition, this estimate does not include any durable medical equipment, anesthesiologist, pathologist, hospital facility charges, laboratory, or radiology fees. Those fees are billed separately by their respective billing companies and are not included in this estimate.
You have a right to dispute (appeal) your bill if it is higher than your Good Faith Estimate.
You may also start a dispute resolution process with the U.S Department of Health and Human Services. If you chose this process, you must pay a $25 fee and start the dispute within 120 calendar days (about 4 months) of the date on the original bill. If the agency reviewing your dispute agrees with you, you will have to pay 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 on your bill.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-877-696-6775.
The estimate is valid for 30 days.