Your Right to a Good Faith Estimate

Know the Expected Cost of Care When You Are Uninsured or Not Using Insurance

Under the federal No Surprises Act, health care providers generally must give patients who do not have health insurance, or who choose not to use insurance for an item or service, an estimate of the expected charges before the item or service is provided.

This is called a Good Faith Estimate.

When You Should Receive an Estimate

If you are uninsured or do not plan to submit the service to insurance, you may ask WellifyCare Medical S.C. for a Good Faith Estimate before scheduling.

For scheduled services, we generally will provide a written estimate:

• within 1 business day after scheduling when the service is scheduled at least 3 business days in advance;

• within 3 business days after scheduling when the service is scheduled at least 10 business days in advance; or

• within 3 business days after your request when you ask for an estimate before scheduling.

  
  

Keep a copy or photograph of the estimate.

What the Estimate Means

The Good Faith Estimate will describe the expected charges for items or services reasonably expected to be provided by WellifyCare Medical S.C. It is an estimate, not a contract or final bill. Your actual care and charges may change if your clinical needs change or if you choose additional services.

The estimate may not include charges from independent laboratories, imaging centers, pharmacies, facilities, consultants, or other clinicians that bill separately. You may ask those providers for separate estimates.

If Your Bill Is Substantially Higher

If a bill from a provider or facility is at least $400 more than that provider's or facility's Good Faith Estimate, you may be eligible to use the federal patient-provider dispute resolution process. Generally, you must start the dispute within 120 calendar days of the date on the original bill.

Starting a dispute does not prevent you from asking the provider to update the bill or negotiate the charge. Eligibility and deadlines are determined under federal rules.

For information about Good Faith Estimates and the federal dispute process, visit:

• https://www.cms.gov/medical-bill-rights/know-your-rights/no-insurance

• https://www.cms.gov/medical-bill-rights/help/guides/good-faith-estimate

• https://www.cms.gov/nosurprises/consumers/medical-bill-disagreements-if-you-are-uninsured

  
  

You may also call the federal No Surprises Help Desk at 1-800-985-3059.

Request an Estimate or Ask a Question

Billing Contact
WellifyCare Medical S.C.
18200 W. Capitol Drive, Suite 200
Brookfield, WI 53045
Phone: (262) 261-8880
Email: info@wellifycare.com

Asking for a Good Faith Estimate will not affect the quality of your care.