Good Faith Estimate & Balance Billing Notice

Clear Path Behavioral Health ("we," "us," or "our") provides telemedicine medication management services to patients located in California. We currently schedule and treat patients only when we have a direct contract with the patient's commercial health insurance plan, and we bill that plan directly for covered services. All patients have the right to choose the self-pay option.

No Surprises Act and California Balance Billing Protections

Federal law (the No Surprises Act) and California law (AB 72) protect patients from unexpected “balance bills” in certain situations - for example, when you receive emergency care, or when you receive non-emergency care at an in-network health care facility from an out-of-network provider without your written consent. In those situations, you generally cannot be billed more than your health plan's in-network cost-sharing amount (copayment, coinsurance, or deductible).

Clear Path Behavioral Health provides telemedicine services only and schedules and treats patients only when we have a direct contract with the patient's commercial health insurance plan. We do not bill patients as an out-of-network provider, and the balance-billing scenarios described above are not expected to arise in the course of your care with us.

If you believe you have received a bill in violation of these protections, or if you have questions about your health plan's coverage or network status, you may contact:

• No Surprises Help Desk (federal): 1-800-985-3059, or www.cms.gov/nosurprises
• California Department of Insurance: 1-800-927-4357
• California Department of Managed Health Care Help Center: 1-888-466-2219

Your Right to a Good Faith Estimate

Federal law separately entitles you to a Good Faith Estimate of expected charges if you do not have health insurance, or if you have health insurance but do not want us to submit a claim to your health plan for an item or service. This right applies whether or not you already have an appointment scheduled.

You can ask for a Good Faith Estimate at any time, including when you contact us to schedule an appointment. A Good Faith Estimate shows the expected charges for the specific items and services we anticipate providing. It is not a bill, and requesting one does not obligate you to receive care from us.

If Your Bill Is Higher Than Your Estimate

If the amount you are billed is at least $400 more than your Good Faith Estimate, you may be able to dispute the bill. You must start the dispute process within 120 calendar days of the date on the original bill. For more information, visit www.cms.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059.

How to Request a Good Faith Estimate

Contact us:

Phone: 310-388-6394
Email: info@clearpathmind.com
Mailing Address: 925 N La Brea Ave., Suite 570, Los Angeles, CA 90038

We will provide your Good Faith Estimate in writing. If your appointment is scheduled 3-9 business days in advance, you will receive it no later than 1 business day after scheduling. If your appointment is scheduled 10 or more business days in advance, you will receive it no later than 3 business days after scheduling. If you request an estimate without scheduling, you will receive it within 3 business days of your request.