No Surprise Act
YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE
(OMB Control Number: 0938-1401)
What is “balance billing” (sometimes called “surprise billing”)?
As Baobab Counseling Center is an outpatient provider and accepts private pay only, they do not accept insurance. “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan.
“Surprise billing” is an unexpected balance bill. You will discuss with Baobab staff prior to beginning your treatment the cost you will pay per service type. The list of all fees for each service type is listed below. The list of all fees for each service type is also listed in the No Surprise Act Informed Consent signed upon beginning treatment.
If you believe you’ve been wrongly billed, you may contact: Georgia Secretary of State at (404) 651-8600
Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.
GOOD FAITH ESTIMATE TABLE OF SERVICES AND FEES
Service code Description Fee for Service (Number of Sessions Will Be Determined as We Progress)
CPT Code 90791- Initial Diagnostic Evaluation with Fully Licensed Therapist: $262.50
CPT Code 90791- Initial Diagnostic Evaluation with Associate Licensed Therapist: $225
CPT Code 90832- Psychotherapy, 16-37 minutes with Fully Licensed Therapist: $87.50
CPT Code 90832- Psychotherapy, 16-37 minutes with Associate Licensed Therapist: $75
CPT Code 90837- Psychotherapy ≥ 53 minutes with Fully Licensed Therapist: $175
CPT Code 90837- Psychotherapy ≥ 53 minutes with Associate Licensed Therapist: $150
CPT Code 90839- Psychotherapy for a Crisis (30-45 minutes): $100
CPT Code +90840- Psychotherapy for a Crisis (add on code for each additional 30 mins): $50
CPT Code 90846- Family Psychotherapy with or without Patient Present, 50 minutes with Fully Licensed Therapist: $175
CPT Code 90847- Family Psychotherapy with or without Patient Present, 50 minutes with Associate Licensed Therapist: $175
CPT Code 90853- Group Psychotherapy: $75
Clinical Intern Hourly rate: $65 per hour
CPT Code 98966-98968- Telephone Assessment & Management: Prorated based on the amount of time spent at hourly rate
CPT Code 98970-98972- Online Digital Evaluation & Mgt (Responding to Email & Text Messages): Prorated based on the amount of time
spent at hourly rate
Teen Intervene (includes two (2) individual sessions with teen and one (1) family session and one follow up family session: $700
Cancelation Fee-Your Therapist Requires a 24-Hour Cancelation Fee: You are Responsible for the Fee of the Appointment Missed
Production of Records- Per 30 minutes: $75
Production of Letter- Per 30 minutes: $75
Total Estimate: This Good Faith Estimate explains your therapist’s rate for each service provided. Your therapist will collaborate with you throughout your treatment to determine how many sessions and/or services you may need to receive the greatest benefit based on your possible diagnosis(es)/presenting clinical concerns.