Good Faith Estimate

Under the No Surprises Act (H.R. 133), health care providers need to give clients or patients who do not have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs. The estimate is based on information known at the time the estimate was created.

  • 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 when applicable.

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

    • You may contact Dancing Dialogue directly to let us know the billed charges are higher than the Good Faith Estimate. You can ask us 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, you will have to pay the higher amount.

  • Make sure your health care provider gives you a Good Faith Estimate within the following timeframes:

    • If the service is scheduled at least three business days before the appointment date, no later than one business day after the date of scheduling;

    • If the service is scheduled at least 10 business days before the appointment date, no later than three business days after the date of scheduling; or

    • If you request a Good Faith Estimate (without scheduling the service), no later than three business days after the date of the request. A new Good Faith Estimate must be provided within the specified timeframes if you reschedule the requested item or service.

  • This is the public disclosure of the "Good Faith Estimate."

Note: A Good Faith Estimate is for your awareness only. It does NOT involve you needing to make any type of commitment.

To learn more and get a form to start the dispute process, go to www.cms.gov/nosurprises or call 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

Understanding Your Estimate

For ongoing mental health treatment:

Because the nature and duration of mental health treatment varies significantly based on individual needs and progress, this estimate reflects our current understanding of your treatment needs. Your actual treatment may require more or fewer sessions than estimated. We will work with you throughout treatment to ensure you are aware of anticipated costs.

This estimate will be updated if:

  • Your treatment frequency or intensity changes significantly

  • Your diagnosis changes in a way that affects treatment approach

  • You begin receiving different types of services

  • Our fees change

  • It appears likely that actual charges will exceed this estimate by $400 or more

Insurance and Payment Information

Dancing Dialogue is out-of-network with all insurance plans. We do not participate in-network with any health insurance companies. We have no hospital affiliations.

If you have health insurance but choose to pay for services out-of-pocket without submitting a claim to your insurance, you are considered a self-pay patient for purposes of the No Surprises Act and are entitled to this Good Faith Estimate.

If you choose to use your out-of-network benefits, we can provide you with documentation (superbills) to submit to your insurance company for potential reimbursement. However, you remain responsible for payment of our full fees at the time of service.

Payment is expected at the time of service unless other arrangements have been made in advance.

If you have questions or concerns, please reach out:

Dancing Dialogue
41 Union Square West, Suite 1528, NYC
1806 Route 9D, Suite 1, Cold Spring, NY
assistant@dancingdialogue.com
(845) 265-1085