No Surprises Act. Health care providers must give clients who don’t have insurance or who are not using insurance an estimate of the bill for counseling services. Clients may elect not to use insurance either because the necessary service does not qualify under your insurance plan OR AGAPE is not an in-network provider. In these cases, getting mental health care could cost you more and there may be certain protections if your insurance plan covers the services you are getting. Ask your insurance plan or patient advocate if you need help knowing if these protections apply to you. To prepare you for any unanticipated expense, you have the right to receive a Good Faith Estimate (GFE) for the total expected cost of services. AGAPE will aim to provide a GFE in writing at least one business day before your appointment. You may also request a GFE before you schedule your first appointment. Please review your GFE carefully and call your insurance carrier if you have questions about how much of these services may be reimbursable. If you receive an invoice that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Please note, if you elect to get mental health care out of network, you may pay more because: • You may be giving up your protections under the law. • You may owe the full costs billed for items and services received. • Your health plan might not count any of the amount you pay towards your deductible and out- of-pocket limit. Except in an emergency, your insurance plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval to cover a service before you get them. If prior authorization is required, ask your health plan about what information is necessary to get coverage.] For questions or more information about your right to a Good Faith Estimate, visit xxx.xxx.xxx/xxxxxxxxxxx or contact the Tennessee Department of Commerce and Insurance at (000) 000-0000. I understand the No Surprises Act. Initial here: _
No Surprises Act. The Parties acknowledge and agree that the Employer’s Plan is subject to requirements under the No Surprises Act that is part of the Consolidated Appropriations Act, 2021 (hereinafter, the “NSA”). BlueCross will process those out-of-network claims subject to the NSA in accordance with the terms of the NSA and its implementing regulations. BlueCross will also engage in the Independent Dispute Resolution (“IDR”) process with providers, as required under the NSA. Fees for IDR services are set forth in Exhibit B. DocuSign Envelope ID: CD93B45A-0105-43E7-9602-5AE5EB65AF29 DocuSign Envelope ID: 00C2B362-1FE5-4A7F-86FB-24039505711D EXHIBIT D TO THE ADMINISTRATIVE SERVICES AGREEMENT MEDICAL MANAGEMENT SERVICES PROVIDED BY BlueCross Employer has selected several of BlueCross’s Medical Management programs for use by Employer in administering its Plan. All services utilize current medical guidelines and standards. While these services are described below, the services may be updated from time to time without prior notice to Employer. MEDICAL MANAGEMENT
No Surprises Act. In accordance with the No Surprises Act, you are entitled to receive a Good Faith Estimate for services not covered by insurance or if you are a self-pay patient.
