Good Faith Estimate

Effective January 1, 2022, a ruling went into effect called the “No Surprises Act” which requires practitioners to provider a “Good Faith Estimate” of the costs you may incur as a result of utilizing out-of-network medical care. The Good Faith Estimate works to show the cost of items and services that are reasonably expected for your health care needs for an item or service, a diagnosis, and a reason for therapy. 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 and will be provided a new “Good Faith Estimate” should this occur. If this happens, federal law allows you to dispute (appeal) the bill if you and your therapist have not previously talked about the change and you have not been given an updated good faith estimate.

Under Section 2799B-6 of the Public Health Service Act (PHSA), health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request, or at the time of scheduling health care items and services to receive a “Good Faith Estimate” of expected charges. Timeline requirements: Practitioners are required to provide a good faith estimate of expected charges for a scheduled or requested service, including items or services that are reasonably expected to be provided in conjunction with such scheduled or requested item or service. That estimate must be provided within specified timeframes: If the service is scheduled at least three business days before the appointment date, no later than one business day after the date of scheduling; If the service is scheduled at least 10 business days before the appointment date, no later than three business days after the date of scheduling; or If the uninsured or self-pay patient requests a good faith estimate (without scheduling the service), no later than three business days after the date of the request. A new good faith estimate must be provided, within the specified timeframes if the patient reschedules the requested item or service.

Common Services at Araya Counseling Services LLC with our “full fee” per session:

90791: Initial therapy intake session = $150

90837: Ongoing therapy appointments (53-60 minutes) = $125

90834: Ongoing therapy appointments (37-53 minutes) = $90

90832: Ongoing therapy appointments (16-36 minutes) = $65

90847: Family appointments (approx 30-55 minutes) = $125

90846: Family appointments without client present: (approx 30 minutes) = $125

PSYSEXEV: Psychosexual Evaluation/Sex Offender Risk Assessment = $500

Additional separate charges will occur in the event that your therapist is involved in services that are not directly providing mental health treatment as outlined above, such as involvement in court proceedings or letter writing on your behalf. These additional non-medical fees are outlined in our consent for services.

Some of the common diagnosis codes treated at Araya Counseling Services are:

F43.20 – Adjustment Disorder, Unspecified

F41.1 – Generalized Anxiety Disorder

F33.9 – Major Depressive disorder, Recurrent episode, Unspecified

F43.10 – Posttraumatic Stress Disorder

F43.89 - Unspecified Trauma- and Stressor-Related Disorder

F52.8 - Other Sexual Dysfunction Not Due to a Substance or Known Psychological Condition

F52.9 - Sexual Dysfunction, Unspecified

F65 - Disorders of Sexual Preference

Please know that this list is not exhaustive and that your diagnosis may not be shown on the list above and may change over time based on many factors. Please speak to your therapist with any questions or concerns you have related to your diagnosis and we can provide you with additional information and/or documentation upon request.

Duration and frequency of services:

As therapists, we recognize that every client’s therapy journey is unique and it is therefore difficult to accurately “predict” how many sessions you will attend and how long you will be engaged in mental health treatment with Araya Counseling Services LLC

Many people attend therapy sessions once weekly, while others choose to attend more or less frequently. Some individuals engage in services for a very short period of time while others remain in treatment for extended periods of time, and still others will “start and stop” services over a period of time in response to changes in symptoms and/or life circumstances.

The duration and frequency of your engagement in mental health treatment may vary and will likely be influenced by many factors including, but not limited to:

Your schedule and life circumstances
Therapist availability
Ongoing life challenges
The nature of your specific mental health condition
Your level of engagement in sessions and in completing homework
Personal finances
Your own personal desire to continue or discontinue treatment

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” can be requested at any time.

If you were to attend standard 55-minute therapy sessions once weekly for 52 weeks at our full fee of \$125 per session, your estimated annual cost for services at Araya Counseling Services LLC would be \$6,500. In the event that you attended an additional 12 standard 55- minute therapy sessions per year, your estimated annual cost for services would be $8,000.

Provider information:

Araya Counseling Services has a physical location and also offers telehealth sessions therapy via a HIPAA secure telehealth platform.

Our physical locations is:

711 Fairview St.

Fountain Inn, SC 29680

Our practice owner is Stefanie Araya, LISW-CP / NPI #1093220337

Our TIN is 99-2594421

Our Type 2 NPI is #1992545784

We have multiple mental health providers employed through Araya Counseling Services and an updated provider list is available at any time by contacting the Araya Counseling Services office at 864-325-5908 or emailing info@arayacounselingservices.com

Please note that the above listed information does not constitute a contract that requires you to obtain the above detailed services through Araya Counseling Services, and likewise does not require the therapists at Araya Counseling Services to provide the detailed services listed above.

DISCLAIMER

This 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 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.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit 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 to ensure that you have accurate information in the event that you are billed more than the amount outlined on this Good Faith Estimate.