No Surprises Act notice.

Your right to a Good Faith Estimate

Under the federal No Surprises Act, if you are uninsured or choose not to use your insurance, you have the right to receive a Good Faith Estimate of the expected cost of care before a scheduled service.

• You may ask for an estimate for any service before you schedule, and you will receive one in writing at least one business day before a scheduled service (three business days if scheduled ten or more days out).
• Call (832) 916-2075 and ask for a Good Faith Estimate.
• If the final bill is at least $400 more than the estimate, you can dispute it through the federal patient–provider dispute resolution process within 120 days of the bill date.
• Keep a copy of your estimate. For more information visit cms.gov/nosurprises (opens in new tab) or call 1-800-985-3059.

Protection from surprise balance billing

When you receive emergency care or are treated by an out-of-network provider at an in-network facility, federal law and Texas law protect you from balance billing — being charged the difference between what your plan pays and the provider’s full charge — for those services. You are only responsible for your in-network cost sharing (copay, coinsurance, deductible). You are never required to give up these protections, and you are not required to get out-of-network care.

How this applies at Gulf Coast Pain & Spine

• We verify your benefits before your first visit and tell you if we are out of network with your plan.
• Procedures performed at an outpatient surgery center may involve a separate facility charge and, if used, a separate anesthesia charge; we will tell you where your procedure will be performed so you can check network status.
• Questions about a bill: call (832) 916-2075 and ask for billing.

If you believe you were wrongly billed

Contact the federal No Surprises Help Desk at 1-800-985-3059 or the Texas Department of Insurance at 1-800-252-3439 (tdi.texas.gov).