Effective January 1, 2022, a ruling went into effect called the “No Surprises Act” which requires practitioners to provider a “Good Faith Estimate” about out-of network care. The Good Faith Estimate works to show 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 therapy. 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 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 therapist 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.
Common Services and Diagnoses:
Common Services:
90971 Clinical Intake 53-60 minutes – $175
90837 Individual Therapy 53-60 minutes – $150.00 (Pending need)
Common Diagnoses:
Below is a list of common diagnoses given in therapy. However, the list is not exhaustive and diagnosis codes can change based on many factors. Please speak to your therapist with any questions or concerns.
Adjustment Disorder (F43.23)
Generalized Anxiety Disorder (F41.1)
Major Depressive Disorder (F33.1)
PTSD/Post Traumatic Stress Disorder (F43.10)
Frequency and Length of Service:
How long you need to engage in therapy and how often you attend sessions will be influenced by many factors including but not limited to:
Your schedule and life circumstances
Therapist availability
Ongoing life challenges
The nature of your specific needs and goals
You and your therapist will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge and/or a new Good Faith Estimate will be issued should your frequency or needs change.
Provider Information:
Business: Good Life Therapy, LLC
Mailing Address: 5000 Westown PKWY Suite #104 West Des Moines, IA 50266
Contact person: Anna Zuidema
Phone: 515-679-3947
Email: info@goodlifetherapyia.com
Organizational National Provider Identifier (NPI): 1093488355
Employer Identification Number (EIN): 86-1872099
Patient Diagnosis:
Patient Diagnosis: Clients must be provided with a diagnosis for ethical, legal, and insurance reasons — as well as required by the No Surprises Act. This diagnosis is only to satisfy the federal requirement for this form. This is not a formal psychological diagnosis. A formal diagnosis occurs after an assessment has been completed. That will take place 1-5 sessions after beginning mental health therapy. Your Good Faith Estimate diagnosis is: Primary Diagnosis: Z73.3 – Stress not elsewhere specified Secondary Diagnosis: F99 – Mental Health Disorder, Not Otherwise Specified
Financial Responsibility Summary:
Below is the amount you would owe if you were to attend therapy for 52 sessions in a year (weekly, 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. Out of an abundance of caution and transparency, only weekly appointments will be quoted. The estimated costs are valid for 12 months from the date of the Good Faith Estimate.
1 Clinical Intake Session (52-60 mins) @ $175
51 Individual Therapy Sessions (33-52 mins) @ $150 = $7,650 (PENDING NEED)
Expected Annual Cost: $7,825.00
*Maximum does not include late cancellation/no show fees or crisis sessions
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 or call 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 or call 800- 985-3059.