Good Faith Estimate
During the scheduling process, you will be provided with a Good Faith Estimate of the anticipated out-of-pocket costs for the evaluation. The estimated cost includes records review, interview(s), administration & scoring of relevant tests, interpretation of all results, written report, and discussion of the results. Additional services can be requested and may require an additional cost. If these additional services are requested, a new cost estimate will be provided.
Please noted that the estimated cost is based on the requested service and the information initially provided by the patient/parent. If the service plan changes based on patient/parent request or additional information, a new estimate will be provided, and the patient/parent can decide whether or not they want the service.
If you are using insurance benefits for the evaluation, we encourage you to confirm your benefits independently as well to avoid unexpected costs. If you would like to do so, member services may ask for the procedure codes (CPT codes) for the evaluation, which will include 90791, 96130, 96131, 96136, and 96137, as well as a tentative ICD-10 diagnosis code, which would be F89.
Disclaimer: The Good Faith Estimate indicates the costs of services that are reasonably expected for your health care needs. The estimate is based on information known at the time the estimate was created. This estimate does not include any unknown or unexpected costs that may arise once the service begins. You will be notified if additional costs will be required. If you are billed more than the Good Faith Estimate, you have the right to dispute the bill. To do this, please contact the health care provider (Dr. Rachael Hoffman: RH@HoffmanNeuropsychology.com). If this is not resolved satisfactorily, you can start a dispute resolution with the U.S. Department of Health & Human Services (HHS). You must start this process within 120 calendar days of the date of the original bill. There is a $25 fee to use the HHS dispute process. If the agency agrees with you, you will pay the amount on this estimate. If the agency disagrees with you, you will pay the higher billed amount to the health care provider. To learn more or start the process, go to: www.cms.gov/nosurprises.