Effective Date: October 4, 2021

Introduction

This Good Faith Estimate Policy establishes procedures for providing clear, written estimates of the cost of mental health services at Branch Counseling and Trauma Center, a private outpatient mental health agency located in Stark County, Ohio. This policy is in accordance with the federal No Surprises Act and is designed to promote transparency, ensure client understanding, and support informed financial decision-making.

Purpose

The purpose of this policy is to ensure that all uninsured and self-pay clients receive a Good Faith Estimate (GFE) for expected charges for non-emergency services prior to receiving care. This supports compliance with federal law and encourages trust between clients and providers.

Scope

This policy applies to all clinicians, intake staff, billing personnel, and administrative staff who interact with or support clients at Branch Counseling and Trauma Center.

Policy

Branch Counseling and Trauma Center will provide a written Good Faith Estimate of expected charges to all uninsured and self-pay individuals. The estimate will reflect the reasonably expected services and associated costs based on the information known at the time of scheduling.
Procedures
1. A GFE must be provided within the following timelines:
• At least 1 business day before the scheduled service if the appointment is made 3 or more days in advance.
• Within 3 business days of scheduling, if the appointment is made more than 10 days in advance.
2. The GFE must include:
• Client’s name and date of birth.
• Description of expected services and diagnosis codes, if known.
• Expected charges for each service.
• Total estimated cost of services.
• Instructions for dispute resolution through the HHS process.
3. A copy of the GFE must be provided to the client and documented in the client’s record.
4. Estimates will be updated if service changes occur or upon client request.
Dispute Resolution
Clients who receive a bill that is at least $400 more than the GFE can initiate a dispute resolution process through the U.S. Department of Health and Human Services (HHS). The GFE document will include instructions on how to begin this process.

Staff Responsibilities

• Clinicians: Provide accurate service codes and expected treatment plans.
• Intake/Admin Staff: Ensure timely delivery of GFEs to eligible clients.
• Billing Department: Maintain GFE documentation for a minimum of six (6) years.

Review and Compliance

Branch Counseling and Trauma Center will review this policy annually to maintain compliance with any changes to state or federal law. Failure to comply with this policy may result in corrective action as outlined in the agency’s HR policies.