No Surprises Act & Good Faith Estimates
Under federal law, you have the right to receive a Good Faith Estimate of expected charges before receiving care. We are committed to full price transparency.
Your Rights Under the No Surprises Act
No Surprise Bills for Emergency Services
If you have an emergency, you cannot be billed more than your in-network cost-sharing amount (copayments, coinsurance, and deductibles) for emergency services at an out-of-network facility. This includes services you may receive after you are in stable condition, unless you give written consent to receive out-of-network care.
Good Faith Estimate
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. You can request this estimate at any time, and it must be provided within specific timeframes.
Protection from Balance Billing
If you receive certain services at an in-network hospital or ambulatory surgical center by an out-of-network provider, you are protected from balance billing. The most you can be billed is your in-network cost-sharing amount.
Independent Dispute Resolution
If you disagree with your bill, you may be able to request an independent dispute resolution process. If your final bill is at least $400 more than your Good Faith Estimate, you have the right to dispute the charges through the federal dispute resolution process.
What Is a Good Faith Estimate?
A Good Faith Estimate is a written estimate of the expected charges for scheduled or requested items or services. Under the No Surprises Act, you have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.
When You Can Request a Good Faith Estimate
You can request a Good Faith Estimate at any time, including before you schedule a dental service. You may also request one for any item or service you expect to receive within the next 12 months. We encourage you to request an estimate before making decisions about your care.
What the Estimate Includes
The Good Faith Estimate will include the expected charges for the scheduled items or services, as well as any reasonably expected items or services that are provided in connection with the scheduled items or services. This may include:
- Dental examination and diagnostic services
- X-rays and imaging
- Cleanings and preventive care
- Fillings, crowns, and restorative procedures
- Oral surgery and extractions
- Orthodontic services
- Any other expected items or services
Timeline for Receiving Your Estimate
If you schedule a service at least 10 business days in advance, we must provide your Good Faith Estimate within 1 business day of scheduling. If you schedule a service at least 3 business days in advance, we must provide your estimate within 3 business days of scheduling. You may also request an estimate at any time.
Important Disclaimer
The Good Faith Estimate is an estimate only. It is not a guarantee of what will be billed. Your actual charges may differ from the estimate if, for example, your condition requires additional or different services, or if complications arise during treatment. If your final bill exceeds the Good Faith Estimate by $400 or more, you have the right to dispute the charges.
How to Request a Good Faith Estimate
Contact Our Office
Call us at (209) 239-2990 or visit us at 715 N Main St, Manteca, CA 95336. Let us know you would like to request a Good Faith Estimate.
Describe Your Expected Services
Tell us what services you expect to receive. This may include specific procedures, or you may request an estimate for a general category of services such as routine dental care.
Receive Your Estimate
We will provide your Good Faith Estimate in writing within the required timeframe. The estimate will list the expected charges for all services, including any related costs.
Review and Compare
Review your estimate carefully. If your final bill exceeds the estimate by $400 or more, you have the right to initiate a dispute resolution process through the federal government.
Dispute Resolution Process
If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the charges. Here is how the process works:
Review Your Bill
Compare your final bill to your Good Faith Estimate. If the difference is $400 or more, you may be eligible to start a dispute.
Submit a Dispute
You must submit your dispute within 120 calendar days of the date on your final bill. You can start a dispute through the CMS independent dispute resolution process.
Independent Review
An independent dispute resolution entity will review the dispute and determine the appropriate payment amount. Both parties will have an opportunity to submit information.
Determination
The dispute resolution entity will issue a determination. This decision is binding unless appealed through the appropriate legal channels.
Dispute Resources
- CMS No Surprises Act Help Line: 1-800-985-6989
- CMS Online: cms.gov/nosurprises
- Our Office: Call (209) 239-2990 with any questions
Rights for Uninsured and Self-Pay Patients
If you are uninsured or choose to self-pay (not using insurance), you have additional rights under the No Surprises Act:
You have the right to a Good Faith Estimate before receiving any scheduled service
Your estimate must include all reasonably expected items and services
You can dispute charges that exceed your estimate by $400 or more
The dispute process is free for the patient
Request Your Good Faith Estimate
We believe in price transparency. Contact our office to request a Good Faith Estimate for any scheduled dental service.