No Surprises Act

You have the right to receive a “Good Faith Estimate”

explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have

insurance or who are not using insurance an estimate of the bill for medical

items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

  • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item.

  • You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

  • Make sure to save a copy or picture of your Good Faith Estimate.

  • For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 815.575.9675.

Cost of Services

Self Pay

If you are choosing to not use insurance benefits, you must let us know:

a) if you are uninsured, or

b) if you are choosing to not have claims submitted to your health insurance. Under these conditions, we will provide you with an estimate of your financial responsibility for services when you contact us to discuss an appointment or inquire about services. Your patient responsibility is payable at the beginning of each service.

Commercial insurance

Your insurance plan decides the amount they will pay us for services and the amount of your patient financial responsibility. Most insurance companies do not tell us this amount, and change the amounts without our knowledge. If we are in-network with your insurance, this means that we have agreed to accept whatever amount they decide to pay for the service. We are also legally obligated to collect all patient cost-sharing amounts. In order to determine your cost of services, you must contact your insurance plan and ask for your patient responsibility for office mental health services at Transformation Behavioral Health. The most common CPT (procedure) codes are:

90791 (diagnostic interview),

90837 (individual therapy),

90847 (family therapy),

90853 (DBT group), and

90849 (teen and parent DBT group).