THE NO SURPRISES ACT

STANDARD NOTICE AND CONSENT DOCUMENTS

(OMB Control Number: 0938-1401)

SURPRISE BILLING PROTECTION FORM

The purpose of this document is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care. You’re getting this notice because this provider or facility isn’t in your health plan’s network. This means the provider or facility doesn’t have an agreement with your plan. Getting care from this provider or facility could cost you more. If your plan covers the item or service you’re getting, federal law protects you from higher bills:

  • When you get emergency care from out-of-network providers and facilities, or

  • When an out-of-network provider treats you at an in-network hospital or ambulatory surgical center without your knowledge or consent.

    Ask your health care provider or patient advocate if you need help knowing if these protections apply to you.

If you sign this form, you may pay more because:

  • You are giving up your protections under the law.

  • You may owe the full costs billed for items and services received.

  • Your health plan might not count any of the amount you pay towards your deductible and out- of-pocket limit. Contact your health plan for more information.

You shouldn’t sign this form if you didn’t have a choice of providers when receiving care. For example, if a doctor was assigned to you with no opportunity to make a change.

Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, your health plan might work out an agreement with this provider or facility, or another one.

ESTIMATE INFORMATION

Out-of-network facility/provider(s) name: Janssen EMDR, LLC

Provider: Abby Janssen, LCSW (Fully Licensed, super bill eligible)

Total cost estimate of what you may be asked to pay: It is your ethical right to determine your goals for treatment and how long you would like to remain in therapy unless you are pursuing mandatory treatment. Please see the breakdown of possible fees on page four.

  • Review your detailed estimate. See page four for a cost estimate for each item or service.

  • Call your health plan. Your plan may have better information about how much of these services are reimbursable. 

  • Questions about this notice and estimate? For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or contact Abby Janssen, LCSW, owner of Janssen EMDR at (262) 208-4557 or email her at abby@janssenemdr.com.

  • Questions about your rights? Contact: The Wisconsin Department of Health Services, at  (800) 362-3002. https://www.dhs.wisconsin.gov

Prior authorization or other care management limitations

Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval that it will cover an item or service before you get them. If prior authorization is required, ask your health plan about what information is necessary to get coverage.

More information about your rights and protections

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.

By my signature, I give up my federal consumer protections and agree I might pay more for out-of-network care.

With my signature, I am saying that I agree to get the items or services from Janssen EMDR, LLC by the assigned provider below:

Abby Janssen, LCSW

With my signature, I acknowledge that I am consenting of my own free will and am not being coerced or  pressured. I also understand that:

  • I’m giving up some consumer billing protections under Federal law.

  • I may get a bill for the full charges for these items and services or have to pay out-of-network cost sharing under my health plan.

  • I was given verbal notice during my consultation call and/or written notice through my client portal prior to my initial appointment explaining that my provider or facility is not  in my health plan’s network, the estimated cost of services, and what I may owe if I agree to be treated by this provider or facility.

  • I got the notice either on paper or electronically, consistent with my choice.

  • I fully and completely understand that some or all amounts I pay might not count toward my health plan’s deductible or out-of-pocket limit.

  • I can end this agreement by notifying the provider or facility in writing before getting services.

IMPORTANT: You don’t have to sign this form. But if you don’t sign, this provider or facility might not treat you.

Print Name:___________________________________________Date:_________________

Signature:__________________________________________________________________


Take a picture or download a copy of this form to keep for your record.

It contains important information about your rights and protections.

ADDITIONAL DETAILS ABOUT YOUR ESTIMATE

FEDERAL TAX ID: 

NPI#: 1093238131

The amount below is only an estimate; it isn’t an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. It doesn’t include any information about what your health plan may cover. This means that the final cost of services may be different than this estimate. Contact your health plan to find out how much, if any, your plan will pay and how much you may have to pay. Some insurance companies only allow certain codes and will not pay for other codes submitted. It is important when you call about your benefits to see what they allow. For example, some plans do not cover couple/marital therapy and do not cover a family session without the client present. 

Knowing what your insurance will and will not cover is important if you want to super bill.

What is Super Billing?

You may request a super bill outlining the services you received and cost to submit to your insurance plan in order to access any out-of-network benefits available to you. Only fully licensed therapists can provide a super bill. Your therapist will disclose to you during the consult call whether or not they are able to provide this to you. This information is also part of the Good Faith Estimate Notice and Consent.

GOOD FAITH ESTIMATE

TABLE OF SERVICES AND FEE

Service code(CPT Code) Description Fee for Service (Number of Sessions Will Be Determined as We Progress )

90791 Initial Diagnostic Evaluation- 60 minutes $200.00

90837 Psychotherapy ≥ 53 minutes  $200.00
(This fee is my hourly rate
& used for all prorated calculations as indicated)

90837 EMDR 90 minute session (add-on codes are not available) $300.00

98966-98968 Telephone Assessment & Management Prorated based on the amount of time spent at hourly rate

98970-98972 Online Digital Evaluation & Mgt Prorated based on the amount of time spent at hourly rate
(Responding to Email & Text Messages)

90791, 90837 EMDR Intensive Program See GFE estimate below $200.00/hour

Cancelation Fee  Your Therapist Requires a 48-Hour Notice  You are Responsible for the Full Fee of the Appointment Missed

Production of Records $15 for first 5 pages, $0.15 for each page after

Legal Fees $400.00/hour

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 diagnosis(es)/presenting clinical concerns. Please note that Place of Service (in office vs. telemental health) is not delineated above since the charges are identical.

GFE Estimate: $200/hour for extended or intensive sessions. Current Intensive package plan: 1 hour documentation review prior to intake (included), 2-hour intake ($400), three 3-hour intensive sessions ($600) and a 2-hour follow-up ($400) session for a total of $ 1,400. We will collaboratively plan any additional sessions in the follow-up.
Additional sessions to the intensive can include an extended 90 minute session ($300) or another intensive 3-hour session ($600).

Charges will be made to the credit card on file at the time of scheduling unless other arrangements are made. Review practice policies, the cancelation policy applies to extended and intensive sessions as well.