No Surprises Act — Good Faith Estimate

1. Information-only purpose; no clinician-patient relationship from the website

This page is informational and describes your rights under the federal No Surprises Act (Public Law 116-260, Division BB, Title I; 45 C.F.R. Parts 149, 150) as applied to outpatient psychology services at Pasadena Clinical Group ("PCG"). The page is not a Good Faith Estimate, and reading it does not create a clinician-patient relationship. The cost figures discussed here are general; the specific Good Faith Estimate ("GFE") issued to you at intake controls. Information on the website is general and does not constitute medical or financial advice and may not be used to diagnose yourself.

2. Your right to a Good Faith Estimate

Under the No Surprises Act and 45 C.F.R. §149.610, you have the right to receive a Good Faith Estimate ("GFE") of the expected charges for the medical items and services you are receiving from PCG, if you are uninsured or are not planning to file a claim with your insurance for the services.

3. Who is entitled to a GFE; what it covers

• You have the right to receive a GFE for the total expected charges of any non-emergency items or services, including related costs such as administrative, intake, evaluation, and treatment services.
• You can ask any provider for a GFE before scheduling, and you can request one at any time.
• For services scheduled at least three (3) business days in advance, you must receive a GFE no later than one (1) business day after scheduling.
• For services scheduled at least ten (10) business days in advance, you must receive a GFE no later than three (3) business days after scheduling.
• For ongoing courses of treatment, GFEs are reissued as required by the No Surprises Act and the implementing regulations.
• Save a copy of your GFE — you may need it if you receive a bill that is substantially higher.

4. How PCG provides your GFE

If you are uninsured or self-pay, PCG provides a written GFE that includes: your name and date of birth; a description of the primary item or service (e.g., 60-minute psychotherapy; 90-minute intake evaluation); applicable CPT/HCPCS service codes and ICD-10 diagnosis codes (or working diagnosis codes); the rendering clinician's name, license number, NPI, and Tax ID where applicable; the expected charge per session and per item; an estimate of the total expected charges across the anticipated course of treatment based on information available at the time; a list of any items or services that may be furnished by other providers and that are not included in the GFE; and the disclaimers required by 45 C.F.R. §149.610(c)(2).

The GFE is an estimate. Actual charges may differ based on changes in your clinical needs, length and frequency of services, and other reasonable factors. Significant changes will trigger a new GFE.

5. Patient-Provider Dispute Resolution (PPDR)

If you are uninsured or self-pay and you receive a bill from PCG that is at least $400 more than the most recent GFE for an item or service, you may initiate the Patient-Provider Dispute Resolution ("PPDR") process administered by the U.S. Department of Health and Human Services through a Selected Dispute Resolution ("SDR") entity. To start a PPDR claim:

• Initiate the dispute within 120 calendar days from the date you received the bill.
• You will need a copy of your bill and your GFE.
• There is a small administrative fee (currently $25, subject to change).
• The SDR entity will review and determine whether a payment adjustment is warranted.
• You are not required to pay the disputed bill while the PPDR is pending; collection actions on the disputed amount are paused.
• For more information and to file: cms.gov/nosurprises · 1-800-985-3059.

6. Surprise-billing protections (federal)

The No Surprises Act protects you from surprise billing in three principal situations: emergency services from out-of-network providers and facilities; non-emergency services from out-of-network providers at certain in-network facilities; and air-ambulance services from out-of-network providers. PCG is an outpatient psychology practice and does not bill for emergency, hospital-based, or air-ambulance services. If, in the rare circumstance that out-of-network professional charges arise (for example, a covering clinician who is not in your insurer's network), the No Surprises Act prohibits balance billing beyond your in-network cost-sharing for protected services unless you have provided a written notice and consent that complies with 45 C.F.R. §149.420 and is permissible for the service in question (note: most mental-health services, including outpatient psychotherapy, are NOT eligible for the notice-and-consent waiver of balance-billing protection).

7. Mental-health parity (MHPAEA)

Under the federal Mental Health Parity and Addiction Equity Act of 2008 ("MHPAEA," 29 U.S.C. §1185a; 42 U.S.C. §300gg-26) and California Health & Safety Code §1374.72/Insurance Code §10144.5, group health plans and California-regulated health insurance policies must provide coverage for mental-health and substance-use disorder services on parity with medical/surgical benefits. If you believe your plan is improperly limiting access, copays, deductibles, or visit limits for mental-health services compared with medical/surgical services, contact your plan, the California Department of Managed Health Care (DMHC) at dmhc.ca.gov, the California Department of Insurance at insurance.ca.gov, or the U.S. Department of Labor (for self-funded ERISA plans) at dol.gov/agencies/ebsa.

8. California protections (Knox-Keene; Health & Safety Code §1371.4 and §1371.9)

California law provides additional balance-billing protections for individuals enrolled in plans regulated by the Department of Managed Health Care (Knox-Keene plans) for emergency and certain non-emergency services. PCG is an outpatient practice and does not provide emergency services; California protections nevertheless apply to any covered out-of-network billing. PCG bills only the patient's in-network cost share when balance-billing protections apply.

9. If you have insurance and are using it

If you are using insurance, the GFE requirements of 45 C.F.R. §149.610 do not currently apply (until rules for insured-patient GFEs are finalized). Your benefits are determined by your insurance plan documents (Evidence of Coverage; Summary of Benefits and Coverage). PCG will furnish good-faith estimates on request and will work with you and your insurer on prior authorization and benefits verification.

10. Charity care and financial hardship

If you are unable to afford care, please discuss with us. PCG considers reduced-fee placements on a case-by-case basis based on availability and clinician determination. Charity-care decisions are at the practice's discretion and are not promised by this page.

11. Disclaimers; not legal or financial advice

This page summarizes federal and California law for informational purposes. It is not legal or financial advice and may be incomplete or out of date. The federal regulations and California statutes referenced above control. For specific advice about your situation, consult an attorney or a qualified billing advocate.

12. Dispute resolution for billing disagreements with PCG

The PPDR process described in Section 5 is the federally established process for uninsured/self-pay billing disputes that exceed the $400 threshold. Other billing disputes between you and PCG are subject to the mediation and binding-arbitration provisions of the Treatment Consent (clinical/medical aspects) and Terms & Conditions (non-clinical aspects), including class-action and representative-action waivers and shortened limitations period.

13. Filing a complaint

You may file a No Surprises Act complaint with the Centers for Medicare & Medicaid Services at 1-800-985-3059 or cms.gov/nosurprises/consumers. Complaints related to California-regulated plans may be filed with the DMHC or California Department of Insurance.

14. Contact

Pasadena Clinical Group · 301 N. Lake Ave, STE 600, Pasadena, CA 91101 · (626) 354-6440 · office@pasadenaclinicalgroup.com