No Surprises Act

Under the No Surprises Act (NSA), uninsured patients and commercially insured patients who choose not to use their benefits are entitled to a good-faith estimate (GFE) of charges from Foresight before scheduled services. If the actual charges by a particular clinician or facility exceed the GFE amount by more than $400, the patient is entitled to dispute the charges under an arbitration process.

A good-faith estimate shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. The estimate is based on the information known to us when we did the estimate.
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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 are billed for $400 more (per clinician) than this good-faith estimate (GFE), you have the right to dispute the bill.

You may contact Third Space Therapy to let us know the billed charges are at least $400 higher than the GFE. You can ask us to update the bill to match the GFE, ask to negotiate the bill, or ask if there is financial assistance available. Please call us at (833) 244-4878.

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 four 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 the GFE. If the agency disagrees with you and agrees with Third Space Therapy, you will have to pay the higher amount.

To learn more and get a form to start the process, go to:
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www.cms.gov/nosurprises or call CMS at 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 CMS at 800-985-3059 .