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Good Faith Estimate 

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Bluestone Clinical PLLC

Under the federal No Surprises Act, individuals who do not have health insurance or who choose not to use their health insurance for a healthcare service generally have the right to receive a Good Faith Estimate of expected charges.

Who Is Eligible?

You may be eligible for a Good Faith Estimate when:

  • You do not have health insurance; or

  • You have health insurance but do not want Bluestone Clinical to submit a claim for the service; and

  • You request an estimate or schedule services at least three business days in advance.

A Good Faith Estimate is generally not required when services are scheduled fewer than three business days in advance.

When Will I Receive the Estimate?

When care is scheduled:

  • Three to nine business days in advance: The estimate will generally be provided within one business day after scheduling.

  • Ten or more business days in advance: The estimate will generally be provided within three business days after scheduling.

You may also request an estimate before scheduling. When you request an estimate without scheduling care, it will generally be provided within three business days.

What Will the Estimate Include?

The Good Faith Estimate will include reasonably expected charges for services to be provided by Bluestone Clinical.

It may include:

  • The anticipated service

  • The applicable diagnostic or billing code, when required

  • The expected charge per session or service

  • The expected frequency of services

  • The period covered by the estimate

  • Any other information required by applicable federal rules

The estimate is based on information known when it is prepared.

Ongoing Psychotherapy

The frequency and duration of psychotherapy depend on clinical needs, treatment goals, client preferences, attendance, progress, medical necessity, and other factors that may not be known at the beginning of treatment.

A Good Faith Estimate for psychotherapy may therefore include an estimated number or range of sessions over a stated period.

The estimate is not a recommendation that you receive a particular number of sessions, and it does not require you to continue treatment.

You and your clinician may discuss changes in treatment frequency or duration at any time.

An updated estimate may be issued if the expected services or charges change substantially.

The Estimate Is Not a Bill

A Good Faith Estimate is an estimate of expected charges. It is not a bill, guarantee, contract, or promise that treatment will cost exactly the amount stated.

Actual charges may differ when:

  • You request additional services

  • The frequency or duration of treatment changes

  • Your clinical needs change

  • An unanticipated service becomes necessary

  • You change your payment method

  • The originally anticipated service is not provided

Bluestone Clinical will make reasonable efforts to discuss foreseeable changes in advance.

Insurance Clients

This federal Good Faith Estimate right primarily applies when you are uninsured or are choosing not to use insurance for the service.

When you use insurance, your insurer determines coverage, deductibles, copayments, coinsurance, medical-necessity requirements, and claim-processing decisions.

An insurance eligibility or benefit quote is not a guarantee of payment.

You remain responsible for amounts assigned to you by your health plan, subject to applicable contracts and law.

Headway and Alma Billing

When billing or insurance administration is handled through Headway or Alma, you may receive eligibility information, estimated client responsibility, invoices, claims information, or other financial notices directly from that platform.

Platform-generated cost estimates are based partly on information supplied by your insurer and may change after the insurer processes the claim.

A formal Good Faith Estimate for uninsured or self-pay services may be provided separately when required.

Questions about Bluestone Clinical’s fees may be directed to Bluestone Clinical. Questions about a platform invoice or processed insurance claim may also need to be directed to Headway, Alma, or the applicable health plan.

What If My Bill Is Higher Than the Estimate?

You may be eligible to use the federal patient-provider dispute-resolution process when:

  • You did not use insurance for the service;

  • You received a Good Faith Estimate;

  • The billed charges from a provider are at least $400 higher than that provider’s estimate; and

  • You submit the dispute within 120 calendar days of the date on the initial bill.

An independent third party will review the estimate, bill, and supporting information to determine an appropriate payment amount.

The dispute process does not prevent you and Bluestone Clinical from discussing or resolving a billing concern directly.

Requesting an Estimate

To request a Good Faith Estimate, contact:

Bluestone Clinical PLLC
Attention: Dolly Skricka, LCSW
Phone: 860-746-2416
Email: dolly@bluestoneclinical.com
Fax: 860-781-9321

Please state that you are requesting a Good Faith Estimate and identify the service you are considering.

Questions or Complaints

Questions about this notice or your estimate may be directed to Bluestone Clinical using the contact information above.

Information about federal medical-billing rights and the patient-provider dispute-resolution process is available through the Centers for Medicare & Medicaid Services.

The federal No Surprises Help Desk may be reached at 1-800-985-3059.

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