No Surprises Act & Good Faith Estimate

Effective date: January 1, 2022 — updated for current practice policies at Revelation Mental Health.

Revelation Mental Health is a private pay online therapy practice owned and operated by Suzanne Maynard, LMFT. Suzanne is licensed to provide therapy services to clients located in Tennessee and Nevada. This page explains your rights under the federal No Surprises Act and your right to receive a Good Faith Estimate of the cost of your care.

1. What Is the No Surprises Act?

The No Surprises Act is a federal law that went into effect on January 1, 2022. It was created to protect patients from unexpected medical bills and to increase transparency around the cost of health care services. While it is often discussed in the context of hospital and emergency care, parts of the law also apply to private pay mental health services.

For clients who are uninsured or who choose not to use insurance and pay out of pocket, the No Surprises Act gives you the right to receive a written Good Faith Estimate of expected costs before you receive services.

2. Your Right to a Good Faith Estimate

If you are an uninsured or self-pay client (you do not have insurance, or you choose not to use your insurance and instead pay privately), you have the right to receive a Good Faith Estimate for the services you request at Revelation Mental Health.

A Good Faith Estimate outlines the expected cost of your mental health services. You can request this estimate at any time before scheduling, when you schedule your first appointment, or at any point during your treatment if your plan of care changes. You will receive the estimate in writing, and you may also request that it be provided electronically.

3. What the Good Faith Estimate Includes

Your Good Faith Estimate is meant to help you understand and plan for the cost of your therapy. It is not a contract or a guarantee — actual costs may vary based on your needs and the number of sessions you choose to attend. However, the estimate will give you a clear picture of what to expect financially.

Each Good Faith Estimate from Revelation Mental Health will include:

Provider information: Suzanne Maynard, LMFT, practice name (Revelation Mental Health), and contact information.
Client information: Your name and relevant identifying details for the estimate.
Diagnosis code(s), if applicable: Any mental health diagnosis codes that are part of your treatment plan, if a diagnosis has been established.
Service code(s): The type of service you are receiving, such as individual online psychotherapy sessions, along with the corresponding procedure (CPT) code(s).
Expected charges: The estimated cost per session, the number of sessions anticipated over a specified period of time (for example, 12 weeks), and the total estimated charges for that period.
Time frame covered: The length of time the estimate covers (for example, three months of weekly sessions).
Disclaimers: Notes that the frequency or duration of therapy may change based on your needs and preferences, which could change the overall cost.

4. If Your Bill Is Higher Than the Estimate

Under the No Surprises Act, you have the right to dispute medical bills that are substantially higher than your Good Faith Estimate. If you receive a bill that is at least $400 more than the total amount listed on your Good Faith Estimate, you may have the option to start a dispute resolution process.

If this happens, you can:

First, contact Revelation Mental Health to review the bill together, compare it to your Good Faith Estimate, and discuss any differences.
If we are not able to resolve the concern directly, you can learn more about your rights and how to start a dispute by visiting www.cms.gov/nosurprises or calling 1-800-985-3059.

To begin a formal dispute process, you must generally start it within 120 calendar days of the date on the bill.

5. How to Contact Revelation Mental Health

If you have questions about your Good Faith Estimate, your fees, or any part of this notice, you are invited to reach out. Clear, respectful communication about finances is an important part of feeling safe and supported in therapy.

For questions or to request a Good Faith Estimate, please visit the Contact page on the Revelation Mental Health website. You can use the secure contact form there to send a message, request a consultation, or ask for a copy of your estimate.

6. Self-Pay Clients and Insurance

Revelation Mental Health operates as a private pay practice. This means that payment is made directly by clients, and the practice does not bill insurance companies on your behalf.

The Good Faith Estimate requirement described here applies to uninsured and self-pay clients. It does not apply to services that are being billed directly to an insurance company. If you choose to submit superbills to your insurance on your own for possible out-of-network reimbursement, your Good Faith Estimate can still help you understand and plan for your expected costs.

If you have any questions about how this law applies to you, please reach out through the Contact page so we can discuss your specific situation.