Agency Fee Policy | OhioGuidestone

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Provider Name: OhioGuidestone
Provider Type: Behavioral Health
Street Address: 343 W. Bagley Rd., Berea, OH 44017
NPI: 1174680557, 1295096758
Taxpayer ID: 34-0720558

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The Fee Policy provides the rates you will be charged for a specific service should you lose your Third Party coverage (Medicare, Insurance, Medicaid, Board Funding, Contract, etc.), if you do not have Third Party coverage, if you choose to pay for a service that is not covered by your Third Party coverage, or if Board Funding is depleted.

These rates apply for individuals who are on a board subsidized sliding fee scale, are 100% self-pay, or who choose to pay for a service that is not covered by Third Party coverage. If you have a Third Party plan such as Medicare or Insurance, etc. you are responsible for copays, deductibles and any other portion that the Third Party plan indicates as your responsibility, at the time of service.

If you are eligible for subsidized board funding based on a sliding scale you will be charged the lesser of either the board sliding scale or the Third Party copay/deductible.

It is critical that you communicate any changes in your Third Party coverage right away to prevent any charges going to directly to you.

Insurance Coverage

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OhioGuidestone is a non-profit organization supported in part by local Alcohol, Drug Addiction and Mental Health Services Boards and various community agencies. Collection of the sliding fee/copay amounts that we offer to you as our client is essential in enabling us to continue to offer our services to the families in our communities. The Agency reserves the right to discontinue services if you refuse to pay your fees. Accounts that are delinquent by 60 days or more from the date of the invoice may be sent to a collection agency.

Please be advised that we are provided a limited amount of funding to support our sliding fee/copay; therefore you will be responsible for the full fee for services once funding is depleted. A fee of $35.00 may be charged for any returned checks. The fees charged are subject to change and any increase or decrease will be passed on to the client and Third Party payers. The Agency will provide you at any time, upon request, a listing of the current fees for services. See DETAILS OF ESTIMATE for additional information.

Details of Estimates

The following is a detailed list of expected charges for behavioral health services, which will be scheduled after your Diagnostic Evaluation, as well as for items or services reasonably expected to be furnished in conjunction with the primary item or service as part of the period of care. Depending on how treatment progresses, more or fewer sessions may be needed. The estimated costs are valid for 12 months from the date of the Good Faith Estimate unless OhioGuidestone provides an updated Estimate.

Mental Health

Diagnostic Evaluation (per encounter) (Code 90791)

Cost per unit $156.60; Sliding fee, if applicable $:

Expected Cost $:

Expected Quantity:

Psychotherapy - Individual (30 minutes) (Code 90832)

Cost per unit, $75.60; Sliding fee, if applicable $:

Expected Cost $:

Expected Quantity:

Psychotherapy - Individual (45 minutes) (Code 90834)

Cost per unit, $98.29; Sliding fee, if applicable $ :

Expected Cost $:

Expected Quantity :

Psychotherapy - Individual (60 minutes) (Code 90837)

Cost per unit, $144.19; Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Psychotherapy - Families - without client present (per encounter) (Code 90846)

Cost per unit, $144.15; Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Psychotherapy - Families - with client present (per encounter) (Code 90847)

Cost per unit, $120.66; Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Psychotherapy - Crisis (1st hour) (Code 90839)

Cost per unit, $205.70; Sliding fee, if applicable $:

Expected Cost $ :

Expected Quantity :

Psychotherapy - Crisis (each additional 30-minutes) (Code 90840)

Cost per unit, $98.16; Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

MH Group Psychotherapy (per encounter) (Code 90853)

Cost per unit, $46.64; Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Community Psychiatric Support Treatment – CPST (per hour) (Code H0036)

Cost per unit, $110.16; Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Group CPST (per hour) (Code H0036)

Cost per unit, $50.68; Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Therapeutic Behavioral Service – TBS (per hour, based upon location) (Code H2019)

Cost per unit, $161.18; Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Group TBS (per hour) (Code H2019)

Cost per unit, $40.56; Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Psychosocial Rehabilitation – PSR (per hour, Community location) (Code H2017)

Cost per unit, $114.55; Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Psychosocial Rehabilitation – PSR (per hour, Office location) (Code H2017)

Cost per unit, $89.30; Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

E&M Services – New Patient (per encounter, Office, EPF; EPF; Straightforward) (Code 99202)

Cost per unit, $116.42; Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

E&M Services – New Patient (per encounter, Office, DET; DET; Low) (Code 99203)

Cost per unit, $169.03; Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

E&M Services – New Patient (per encounter, Office, COMP; COMP; Moderate) (Code 99204)

Cost per unit, $259.20; Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

E&M Services – New Patient (per encounter, Office, COMP; COMP; High) (Code 99205)

Cost per unit, $325.77; Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

E&M Services – Established Patient (per encounter, Office) (Code 99211)

Cost per unit, $30.68; Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

E&M Services – Established Patient (per encounter, Office, PF; PF; Straightforward) (Code 99212)

Cost per unit, $67.33; Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

E&M Services – Established Patient (per encounter, Office, EPF; EPF; Low) (Code 99213)

Cost per unit, $113.92 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

E&M Services – Established Patient (per encounter, Office, DET; DET; Moderate) (Code 99214)

Cost per unit, $168.12 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

E&M Services – Established Patient (per encounter, Office, COMP; COMP; High) (Code 99215)

Cost per unit, $227.10 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

E&M Services w/ Add-on Psychotherapy (60-minutes) (Code 90838)

Cost per unit, $154.37 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

E&M Services w/ Add-on Psychotherapy (45-minutes) (Code 90836)

Cost per unit, $117.02 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

E&M Services w/ Add-on Psychotherapy (30-minutes) (Code 90833)

Cost per unit, $92.13 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Interactive Complexity (per encounter) (Code 90785)

Cost per unit, $16.55 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Mental Health Nursing Services – Individual (per hour, Office, LPN) (Code H2017)

Cost per unit, $127.07 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Mental Health Nursing Services – Individual (per hour, Office, RN) (Code H2019)

Cost per unit, $231.14 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Day Treatment (per diem) (Code H2020)

Cost per unit, $257.44 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Day Treatment (per hour less than 2.5 hours) (Code H2012)

Cost per unit, $51.48 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Intensive Home Based Treatment – IHBT (per hour) (Code H2015)

Cost per unit, $187.50 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Screening Brief Intervention Referral to Treatment - SBIRT (29-minutes and under) (Code G0396)

Cost per unit, $35.30 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

SBIRT (30-minutes and over) (Code G0397)

Cost per unit, $65.56 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Assertive Community Treatment (per encounter) (Code H0040)

Cost per unit, $355.04 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Child and Adolescent Needs and Strength (CANS) Assessment (Code H2000)

Cost per unit, $240.20 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Substance Use

SUD Group Psychotherapy (per encounter) (Code H0005)

Cost per unit, $52.82 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

SUD Peer Recovery Support (per hour) (Code H0038)

Cost per unit, $87.44 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

SUD Targeted Case Management (per hour) (Code H0006)

Cost per unit, $110.16 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

SUD Intensive Outpatient – IOP (per diem) (Code H0015)

Cost per unit, $211.24 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

SUD Urine Dip (per screen) (Code H0048)

Cost per unit, $20.41 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

SUD Nursing Services – Individual (per hour, Office, RN) (Code T1002)

Cost per unit, $231.14 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

SUD Nursing Services – Individual (per hour, Office, LPN) (Code T1003)

Cost per unit, $164.22 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

SUD Group Counseling Partial Hospitalization (per diem) (Code H0015)

Cost per unit, $316.86 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

SUD Low Intensity Residential Treatment ASAM 3.1 (per diem) (Code H2034)

Cost per unit, $215.30 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

SUD High Intensity Residential Treatment ASAM 3.5 (per diem) (Code H2036)

Cost per unit, $301.18 Sliding fee, if applicable $ :

Expected Cost $ :

Expected Quantity :

Total Estimated Cost

Total Estimate Cost:

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Good Faith Estimate Disclaimer

This Good Faith Estimate shows the cost of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that provider or facility, federal law allows you to dispute the bill.

The Good Faith Estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate.

If you are billed for more than this Good Faith Estimate, you may have the right to dispute the bill.

You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.

If you dispute your bill, the provider or facility cannot move the bill for the disputed item or service into collection or threaten to do so, or if the bill has already moved into collection, the provider or facility has to cease collection efforts. The provider or facility must also suspend the accrual of any late fees on unpaid bill amounts until after the dispute resolution process has concluded. The provider or facility cannot take or threaten to take any retributive action against you for disputing your bill.

There is a $25 fee to use the dispute process. If the Selected Dispute Resolution (SDR) entity reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate, reduced by the $25 fee. If the SDR entity disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to www.CMS.gov/nosurprises/consumers or call 1.800.985.3059.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.CMS.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1.800.985.3059.

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed an amount that does not match this estimate.

Consent/Release

I acknowledge that the information that I have provided is accurate and true. In consideration of the services rendered or about to be rendered to me, I agree to be financially responsible and obligated to pay the fees that are stated within this agreement, including any updates to the stated rates. An updated copy of rates is available upon request. I also understand that I may be responsible for the full fee for all services that I receive at the Agency once funding for the services is no longer available and/or my funder has indicated that I am responsible for payment.

I understand that 42 CFR Part 2 generally requires the Agency to have my consent before releasing information about any substance use disorder services. For the purpose of healthcare operations, including but not limited to, compliance, billing and reimbursement of services, and authorization to provide services, I give the Agency permission to release any and all information necessary for healthcare operations, including all of my substance use disorder records. The information may include, but is not limited to: name, address, diagnosis, dates and times of service, provider, id number, and other demographic, economic, and social details. I authorize the information to be released to the following entities identified on this form: Alcohol, Drug Addiction, and Mental Health Services Board of my County of Residence; the Primary and Secondary Insurance Companies; Medicaid; Medicare; MyCare Ohio; Ohio Department of Mental Health and Addiction Services; the Ohio Behavioral Health Information System; the Court or Juvenile Court; Netsmart, which is an electronic data interchange, Amazon Web Services, which is an electronic record storage provider; and the Private Payer. I also grant permission for the information to be released to other payer sources not identified on this form, including but not limited to, new payers identified after this form was initially completed. To request additional information regarding to whom information was disclosed for these purposes, please contact the Agency's Privacy Officer at 440.260.8226.

I hereby assign directly to the Agency all insurance benefits otherwise payable to me and authorize payment to be made directly to the Agency. I understand that any payments made to me by my insurance company or Medicare must be forwarded to the Agency or I will be charged the full fee for the cost of the services.

I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire one year after all services that I receive from the Agency have been paid.

I understand that, in certain circumstances, I might be denied services if I refuse to consent to a disclosure for purposes of payment.

Signatures

Is Client an Adult (18+)?: *

**If you are signing the form on behalf of someone else and you are not the client's parent or guardian, you must provide the Agency with legal paperwork verifying your status as the client's personal representative. Acceptable forms of documentation include but are not limited to court order appointing guardian, durable power of attorney, and grandparent power of attorney. To upload this paperwork, please find the "Document Upload" section on this form and upload the required documents.

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eSignature Consent

By clicking the "Submit" button, you agree to use electronic records and signatures. At any time, you may request a paper copy of any record provided or made available electronically to you by us. You will have the ability to receive email copies of documents you have submitted by entering your email address during the document submission process. If you do not have an email address, PRINT A COPY OF THIS RECORD prior to submission. If you decide to receive notices and disclosures from us electronically, you may at any time change your mind and tell us that thereafter you want to receive required notices and disclosures only in paper format. If you elect to receive required notices and disclosures only in paper format, it will slow the speed at which we can deliver services to you and complete certain steps in transactions with you. Further, you would no longer be able to use the OhioGuidestone Website eSignature System to receive required notices and consents electronically from us or to electronically sign documents from us. This consent to use of electronic records and signatures will apply to this and future records sent electronically to you by us. You may contact us to let us know of your changes as to how we may contact you electronically, to request paper copies, and to withdraw your prior consent to receive notices and disclosures electronically by sending an email to Compliance@OhioGuidestone.org.

The minimum system requirements for using the OhioGuidestone Website eSignature System may change over time. By clicking “Submit,” you agree that until or unless you notify us as described above, you consent to receive exclusively through electronic means all notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to you during the course of your relationship with OhioGuidestone.