What Is a Good Faith Estimate
Under the No Surprises Act (Consolidated Appropriations Act, 2021) and implementing regulations at 45 CFR Part 149, effective January 1, 2022, you have the right to receive a Good Faith Estimate (GFE) of expected charges for any healthcare item or service you receive from Aura Integra Behavioral Health, PLLC as an uninsured or self-pay patient.
When You Will Receive a GFE
- If your service is scheduled 10 or more business days out: you will receive your GFE within 3 business days of scheduling.
- If your service is scheduled 3–9 business days out: you will receive your GFE within 1 business day of scheduling.
- If you request a GFE and have not yet scheduled a service: you will receive it within 3 business days of your request.
- If the scope of services changes: you will receive a new GFE at least 1 business day before the service is furnished.
- For recurring services (such as ongoing medication management or psychiatric care): a single GFE covering up to 12 months of care may be issued.
What Your GFE Will Include
- Your name and date of birth
- A description of the services and the scheduled date
- An itemized list of expected charges, including relevant procedure codes
- The provider's name, National Provider Identifier (NPI: 1982532511), and Tax Identification Number
- Expected diagnosis codes
- A disclaimer that actual charges may differ from the estimate
- A statement of your right to dispute charges that substantially exceed the estimate
Your Right to Dispute
If you receive a bill that is substantially more than your Good Faith Estimate — generally $400 or more — you have the right to dispute the bill through the Patient-Provider Dispute Resolution (PPDR) process. Disputing a bill will NOT affect the quality of care you receive.
To start a dispute or learn more, visit cms.gov/nosurprises or call 1-800-985-3059.
Important Disclaimers
- A Good Faith Estimate is not a contract and does not obligate you to obtain services from Aura Integra Behavioral Health, PLLC.
- A Good Faith Estimate is only an estimate of expected charges. Actual charges may be higher or lower depending on what services are actually provided.
- Additional items or services may be recommended as part of your care that are not reflected in this estimate.
- Good Faith Estimates are retained as part of the medical record for at least 6 years.
Current Self-Pay Rates
Your individualized Good Faith Estimate will identify the services reasonably expected for your care, their frequency, and the expected total charge.
| Service | Current Fee |
|---|---|
| Initial Psychiatric Evaluation (60 min) | $300 |
| Standard Medication-Management Follow-up (25–30 min) | $150 |
| Extended Medication-Management Follow-up (50–60 min) | $250 |
| ADHD Diagnostic Evaluation (two-part evaluation) | $350 total |
| Adult MOUD/Buprenorphine Initial Evaluation and Induction Planning (60–75 min) | $300 |
| Adult MOUD/Buprenorphine Follow-up (25–30 min) | $150 |
| Oral Naltrexone Management Follow-up | $150 |
| Clinician Letters, Forms, or Record Review Outside Ordinary Treatment Documentation | $50 per 30 min |
| Superbill on Request (for out-of-network reimbursement) | No charge |
| Missed Appointment or Late Cancellation, after one waived occurrence in a rolling 12 months | $90 |
Laboratory, pharmacy, injection-administration, and outside-provider charges are not included unless expressly listed in your individualized estimate.
If you have applied for and been approved for the practice's income-based sliding scale, your Good Faith Estimate reflects your adjusted fee. Sliding-scale tiers and documentation requirements are published on the Insurance and Fees page.
How to Request a GFE
Contact us at billing@auraintegra.com or 508-978-6455. Any question about cost is treated as a Good Faith Estimate request.
More Information
For more information about your rights under the No Surprises Act, visit cms.gov/nosurprises or call 1-800-985-3059.