Good Faith Estimate
Notice: You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (800) 985-3059.
Under Section 2799B-6 of the Public Health Service Act (known as the “No Surprise” Act) as of January 1, 2022, healthcare providers are required to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services called a “Good Faith Estimate” (GFE) explaining how much your medical care will cost.
This new regulation is designed to provide transparency to patients regarding their expected medical expenses and to protect them from surprises when they receive their medical bills. It allows patients to understand how much their health care may cost before they receive services.
There are several factors that make it challenging for Arevalo Counseling & Mentoring, LLC to provide this estimate as treatment times vary for individuals in therapy depending on their goals and motivation for seeking treatment. Please remember that ultimately it is your decision when to terminate therapy services.
At Arevalo Counseling & Mentoring, LLC, we are required to provide a diagnosis for all clients for both ethical, legal, and insurance reasons -- as well as required by the "No Surprises Act". A formal diagnosis occurs after an assessment has been completed. That will take place within the first 3 sessions after beginning Psychotherapy. If you choose to decline a formal diagnosis, we will not update the GFE. It is within your rights to decline a diagnosis per state and federal guidelines.
Common Diagnosis Codes at Arevalo Counseling & Mentoring, LLC: Below are some common diagnosis codes, please note that this list is not exhaustive. Diagnosis codes can change based on many factors. Please speak to your therapist with any questions or concerns.
Adjustment Disorder (F43.23)
Major Depressive Disorder, Moderate, Recurrent (F33.1)
Generalized Anxiety Disorder (F41.1)
Bipolar I and Bipolar II (F31.10 and F31.81)
Borderline Personality Disorder (F60.3)
Arevalo Counseling & Mentoring, LLC recognizes it is not possible for a psychotherapist to know, in advance, what services and how many psychotherapy sessions may be necessary or appropriate for a given person, as everyone’s therapeutic journey is unique. How long you need to engage in therapy and how often you attend sessions will be influenced by many factors including
Your schedule and life circumstances
Therapist availability
Ongoing life challenges
The nature of your specific challenges and how you address them
Personal finances
As a result, your total cost of services will depend upon your individual circumstances, the type and amount of services that are provided to you, and the number of sessions you attend. You and your therapist will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge and/or a new "Good Faith Estimate" will be issued should your frequency or needs change.
According to the American Psychological Association, “on average 15 to 20 sessions are required for 50 percent of patients to recover as indicated by self-reported symptom measures”. Additionally, they state that through the working relationship between the client and counselor sometimes the preference is for “longer periods (e.g., 20 to 30 sessions over six months), to achieve more complete symptom remission and to feel confident in the skills needed to maintain treatment gains”.
Common Services at Arevalo Counseling & Mentoring, LLC:
90791: BioPsychoSocial Assessment -$200
90834: 45–50-minute Psychotherapy Session ($125)
90837: 53+ minute extended psychotherapy Session ($150)
90846/47: Family/Couples Psychotherapy Session ($165)
Where Arevalo Counseling & Mentoring, LLC provides services:
In-office services for clients in Las Vegas, NV
Via teletherapy for clients in California, Nevada, Arizona, and Florida.
Arevalo Counseling & Mentoring, LLC office locations:
1070 W. Horizon Ridge Pkwy, Suite 210, Henderson, NV 89012
6268 S. Rainbow Blvd, Suite 110, Las Vegas, NV 89118
Provider Information:
Provider Name: Arevalo Counseling & Mentoring, LLC
NPI: 1427550599
TAX ID: 81-4815128
Email: contactus@acm-llc.com
Phone #: (702) 970-3535
Fax #: (702) 441-0915
Good Faith Estimate
For a good faith estimate: the amount you would owe if you were to attend therapy for 52 sessions in a year (weekly, without skipping any weeks for holidays, break, vacation, unplanned events/sickness, etc.). The "Good Faith Estimate" requires practitioners to provide an exact estimate and not a range. Out of an abundance of caution and transparency, we will only quote weekly appointments.
90791: BioPsychoSocial Assessment ($200) + 90834: 45-50 minute-Psychotherapy session ($150) for 51 weeks = $6,575.
90791: BioPsychoSocial Assessment ($200) + 90837: 53+ minute extended Psychotherapy session ($150) for 51 weeks = $7,850.
90791: BioPsychoSocial Assessment ($200) + 90847/46: Family/Couples Psychotherapy session ($165) for 51 weeks = $8,615.
The above examples are provided to give an idea of the financial expectations for a calendar year. The frequency and duration is dependent on your individual needs and goals.
We look forward to talking with you and answering any questions you may have about the “No Surprises” Act and Good Faith Estimates.
Good Faith Estimate Disclaimer
The Good Faith Estimate shows the costs 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, federal law allows you to dispute (appeal) the bill.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
You may reach out to us at contactus@acm-llc.com or call (702) 970-3535 to let us know the billed charges are higher than the Good Faith Estimate. You can ask us 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.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
For questions or more information about your right to a GFE or the dispute process, visit www.cms.gov/nosurprises. To learn more about and get a dispute form to start the process, please go to www.cms.gov/nosurprises or call (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 a higher amount.