Good Faith Estimates
A written estimate of expected charges before items or services are provided
You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services, both upon request and when scheduling those items or services. This includes related costs such as medical tests, prescription drugs, equipment, and facility fees.
Good Faith Estimates for Uninsured and Self-Pay Patients
Under federal law, (the No Surprises Act and implementing regulations), health care providers and facilities are required to give patients who do not have health care coverage — or who choose not to use their health care coverage for a service — a written estimate of expected charges before those items or services are provided.
This Good Faith Estimate does not include any unexpected services that may be needed during your visit or stay, including care due to complications or unanticipated tests or procedures.
When Will I Receive My Good Faith Estimate?
If your appointment is scheduled 3 or more business days in advance: Witham will provide your Good Faith Estimate in writing within 1 business day after scheduling.
If your appointment is scheduled 10 or more business days in advance: Witham will provide your Good Faith Estimate in writing within 3 business days after scheduling.
If your estimate was requested before scheduling: Witham will provide your Good Faith Estimate in writing within 3 business days of your request.
If your appointment is scheduled less than 3 business days in advance: A Good Faith Estimate is not required; however, you may still request one.
What If My Bill Is Higher Than My Good Faith Estimate?
If you receive a bill that is $400 or more above the amount listed in your Good Faith Estimate, you have the right to dispute the bill. To initiate a dispute, you must contact the U.S. Department of Health and Human Services (HHS) within 120 calendar days of the date on your original bill.
Please save a copy of your Good Faith Estimate and your bill for your records.
For Questions or More Information
- For questions or more information about your rights under the No Surprises Act:
Visit: www.cms.gov/nosurprises - Email: FederalPPDRQuestions@cms.hhs.gov
- Call: 1-800-985-3059
Good Faith Estimates for Insured Patients
Under Indiana law, patients with health insurance or other coverage may request an estimate of expected charges for non-emergency health care services that have been ordered, scheduled, or referred. Witham Health Services is required to provide that written estimate within 5 business days of receiving your request.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs such as medical tests, prescription drugs, equipment, and facility fees.
What If My Bill Is Higher Than My Good Faith Estimate?
If the actual charges for your health care services exceed the Good Faith Estimate by the greater of (i) $100 or (ii) 5%, Witham Health Services will provide you with a written explanation of why the charges exceeded the original estimate.
If you have questions about differences between your estimate and your bill, you may also contact your health plan for information about how your benefits were applied.
Please save a copy of your Good Faith Estimate for your records.