Good Faith Estimate Arthroscopy Shoulder Surgery

Panacea Medical Center

Good Faith Estimate Arthroscopy Shoulder Surgery Date of Estimate: 02/25/2022

Panacea Medical Center 444 Cedar Street, Suite 920 St. Paul, MN 55101

No Surprises Act for Self-Pay / Uninsured Individuals Under Section 2799B-6 of the Public Health Service Act and effective Jan 1st, 2022, health care providers and health care facilities are required to inquire about a patients' health insurance status and provide a Good Faith Estimate of expected charges for all schedulable items and services to individuals who are not enrolled or covered in a health plan or a Federal health care program, or not seeking to file a claim with their plan or coverage. The Good Faith Estimate must include expected charges for the items or services that are reasonably expected to be provided together with the primary item or service, including items or services that may be provided by other providers and facilities. However, the Health and Human Services (HHS) will exercise enforcement where a Good Faith Estimate does not include expected charges from other providers or facilities that are involved in the patient’s care. The Good Faith Estimate must be provided in written form (either paper or electronically) to self-pay or uninsured individuals within the following timeframes:  No later than 1 (one) business day after the date of scheduling when a primary item or service is scheduled at least 3 business days before the date of furnishing;  No later than 3 (three) business days after the date of scheduling when a primary item or service is scheduled at least 10 business days before such item or service is the date of furnishing; or  No later than 3 business days after the date of the request when a good faith estimate is requested. HHS established a patient-provider dispute resolution (PPDR) process to determine a payment amount when an uninsured or self-pay individual is billed an amount “substantially in excess” of the Good Faith Estimate. If billed charges are at least $400 more than the Good Faith Estimate (for any facility or provider listed on the Good Faith Estimate) then the patient has right to initiate the PPDR process within 120 calendar days of receipt of the bill. Please see disclaimer section on last page of this Good Faith Estimate for more information for your rights with the dispute process.

Good Faith Estimate: 02/25/22

General Information Patient Information First Name

Middle Name

Last Name

Clark

Duckling

Date of Birth

ID Number

Email Address

01/15/1980

12234567

donald.duckling@email.com

Donald

Mailing Address

123 Bird Avenue, Duck City, FL 654321 Phone Number

Contact Preference

222-345-4321

[ ] By mail

[ x ] By email

Clinical Information Primary Service or Item Requested / Scheduled

Arthroscopy Shoulder Surgery Primary Diagnosis Description

Primary Diagnosis Code

Superior glenoid labrum lesion of left shoulder, initial encounter

S43.432A

Secondary Diagnosis Description (if applicable)

Secondary Diagnosis Code

N/A

Convening Facility / Provider Information Facility Name

National Provider ID

Taxpayer ID Number

Hospital ABC

xxxxxxxxxxx

xx-xxxxxx

Phone Number

Email

(xxx) xxx-xxxx

Email address

Facility Address

Street, City, State and Zip Code Facility Contact

First and Last Name

Has the Primary Service been scheduled yet?

Date of Procedure

[ x ] Yes

03/05/2022

[ ] No

Good Faith Estimate: 02/25/22

Expected Charges from Convening Facility / Provider Date of Procedure: 03/05/2022 Service/Item

Service Code

Quantity

Expected Cost

Shoulder Arthroscopic Surgery

29824

1

$ 2,379.00

Surgical Decompression

29826

1

$ 2,271.00

Facility Anesthesia Charge

370

4

$ 2,062.00

Recovery Room

710

3

$ 1,168.00

Fentanyl Citrate Injection

J3010

2

$ 26.00

Ondansetron HCL Injection

J2405

3

$ 23.00

Ringers Lactate Infusion

J7120

1

$ 39.00

Injection Propofol 10 mg

J2704

1

$ 36.00

Injection Midazolam

J2250

3

$ 21.00

Cefazolin injection

J0690

2

$ 0.00

Pharmacy General

250

10

$ 120.00

C1713

2

$ 1,050.00

Supplies Non-Sterile

271

3

$ 450.00

Supplies Sterile

272

10

$ 1,800.00

29824

1

$ 1,063.00

29826

1

$ 267.00

Anchor/Screw

Professional Charges – Orthopedic Surgeon Professional Charges – Orthopedic Surgeon

Total Expected Cost:

$12,805.00

Notes:

Good Faith Estimate: 02/25/22

Expected Charges from Co-Provider Co-Provider Information Provider Name

National Provider ID

Taxpayer ID Number

Hospital ABC

xxxxxxxxxxx

xx-xxxxxx

Provider Contact

Phone Number

Email

First and Last Name

(xxx) xxx-xxxx

Email address

Facility Address Street, City, State and Zip Code

Service/Item Anesthesiology/CRNA

Service Code

Quantity

01630

1

Total Expected Cost:

Expected Cost $832.00

$832.00

Notes:

Good Faith Estimate: 02/25/22

Summary of All Expected Charges Facility / Provider Name

Estimated Total Cost

Panacea Health Systems

$12,895.00

Anesthesiologist/CRNA

$832.00

Total Expected Cost:

$13,637.00

There may be additional items or services the convening provider or facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the Good Faith Estimate. Below is a list of those items or services that require separate scheduling and are expected to occur before or following the expected period of care for the primary item or service. A separate Good Faith Estimate will be provided upon scheduling or upon request of the listed items or services. • • •

Pre-operative Diagnostic Services (i.e., Electrocardiogram) Lab tests Physical Therapy Services

Good Faith Estimate: 02/25/22

Disclaimers •

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 and actual items, services, or charges may differ from the Good Faith Estimate.

•

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. If your bill is higher than this Good Faith Estimate, 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. If your bill is $400 greater than this Good Faith Estimate, you may also start a formal 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. To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059 The initiation of the patient-provider dispute resolution process will not affect the quality of health care services furnished to an uninsured individual by a provider or facility. This Good Faith Estimate is not a contract and does not require you to obtain the items or services from any of the providers or facilities listed in this Good Faith Estimate. Please retain a copy of this Good Faith Estimate for your records. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call No Surprises Help Desk at 1-800-985-3059.

Good Faith Estimate: 02/25/22

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