Your Rights Under the No Surprises Act (NSA)

Under the No Surprises Act, you are protected from unexpected medical bills when you receive emergency care or certain non‑emergency services from out‑of‑network providers at in‑network facilities. These protections ensure you are not charged more than the in‑network cost‑sharing amount for covered services.

Protection From Surprise Billing:
Surprise billing—also known as balance billing—occurs when an out‑of‑network provider bills you for the difference between their charge and what your insurance plan agrees to pay. The No Surprises Act prohibits this in the following situations:

• Emergency services, regardless of where they are provided

• Non‑emergency services at an in‑network hospital or ambulatory surgical center

• Air ambulance services from out‑of‑network providers

You cannot be billed more than your plan’s in‑network rate for these services.
 
Good Faith Estimates for Uninsured or Self‑Pay Patients
If you are uninsured or choose to self‑pay, you have the right to receive a Good Faith Estimate explaining the expected cost of your care.
You have the right to:

• Receive a written estimate of expected charges before your service

• Request an estimate for any service at any time

• Dispute a bill that is $400 or more above your Good Faith Estimate

Good Faith Estimates include expected costs for items and services reasonably associated with your care.
Dispute Resolution
If your final bill is at least $400 more than your Good Faith Estimate, you may initiate the Patient‑Provider Dispute Resolution Process through the U.S. Department of Health & Human Services (HHS).
You must start the dispute process within 120 days of receiving the bill.
What You Are Responsible For
You are still responsible for:

• Your in‑network copayments, coinsurance, and deductibles

• Any services not covered by your insurance plan

• Services you voluntarily choose to receive from an out‑of‑network provider after signing a Notice and Consent form

If You Believe You’ve Been Wrongly Billed
You may contact:
U.S. Department of Health & Human Services No Surprises Help Desk: 1‑800‑985‑3059 Website: https://www.cms.gov/nosurprises (cms.gov in Bing)
Disclaimer
This information is provided to help patients understand their rights under the No Surprises Act. It is not legal advice. For questions about your specific situation, please contact your insurance provider or a qualified legal professional.
If you want, I can also create:

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give me a wisconsin specific one for a new website launch for a mental health private practice called "Therapeutic Solutions of WI"
Below is a Wisconsin‑specific, website‑ready No Surprises Act (NSA) disclosure tailored for your mental health private practice, Therapeutic Solutions of WI. It’s written in a professional, compliant, patient‑friendly tone, suitable for a new website launch, and aligned with Wisconsin billing expectations for private‑pay and insurance‑based outpatient mental health services.
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No Surprises Act & Good Faith Estimate Notice
Therapeutic Solutions of WI • Wisconsin Mental Health Practice
Your Rights Under the No Surprises Act (NSA)
The No Surprises Act protects clients from unexpected medical bills when receiving certain types of care. While many NSA protections apply to emergency and hospital‑based services, outpatient mental health practices—like Therapeutic Solutions of WI—must provide Good Faith Estimates to clients who are uninsured or self‑pay.
This ensures you understand the expected cost of your services before you receive them.
Good Faith Estimate (GFE) for Uninsured & Self‑Pay Clients
If you are not using insurance, or if you choose to self‑pay, you have the right to receive a Good Faith Estimate of the expected charges for your mental health services.
Your Good Faith Estimate will include:

• The type of service you are scheduled for

• The expected number of sessions

• The estimated cost per session

• Any additional fees that may reasonably apply

You may request a Good Faith Estimate at any time, even if you are not yet scheduled for services.
Wisconsin‑Specific Billing Notes
In Wisconsin, outpatient mental health services are often billed per session. Therapeutic Solutions of WI provides transparent pricing for all services, including:

• Initial diagnostic evaluations

• Individual therapy sessions

• Family or parent sessions

• Telehealth services

If you plan to use insurance, your in‑network cost‑sharing (copays, coinsurance, deductibles) will apply according to your plan. If you are out‑of‑network, you may choose to self‑pay and receive a Good Faith Estimate.
Dispute Resolution Rights
If you receive a bill that is $400 or more above your Good Faith Estimate, you may start the Patient‑Provider Dispute Resolution Process through the U.S. Department of Health & Human Services (HHS).
You must begin this process within 120 days of receiving the bill.
What You Are Still Responsible For
Even with NSA protections, you are responsible for:

• Your in‑network copayments, coinsurance, and deductibles

• Services not covered by your insurance plan

• Services you choose to receive after signing a Notice & Consent form (rare in outpatient mental health)

• Missed appointment or late‑cancellation fees, if applicable
   

If You Believe You’ve Been Wrongly Billed
You may contact:
U.S. Department of Health & Human Services No Surprises Help Desk: 1‑800‑985‑3059 Website: https://www.cms.gov/nosurprises (cms.gov in Bing)
You may also contact your insurance provider for questions about coverage or benefits.
Disclaimer
This notice is provided to help clients understand their rights under federal law and Wisconsin billing practices. It is not legal advice. For questions about your specific situation, please speak with your insurance provider or a qualified legal professional.