No SurpriseS
Good Faith Estimate for Health Care Items and Services
No Surprise Act
Instructions Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to provide a good faith estimate of expected charges for items and services to 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.
Refine Psychiatry is out of network and isn’t covered under your health insurance plan network.
Care from our providers could cost you more than providers covered in your network. You can contact your health insurance plan to find an in-network provider. If there isn’t one, your health plan might work out an agreement with this provider or another one.
To learn more about the Good Faith Estimate, please visit: www.cms.gov.
Provider Information:
Office phone: 323-207-6019
Dr. Jill Norman
NPI#1366817983
drnorman@refine-psychiatry.com
Dr. Ashley Pirozzi
NPI#1194109298
drpirozzi@refine-psychiatry.com
Location of Services:
Dr. Norman
22 West Micheltorena, Unit A East
Santa Barbara, CA 93101
Dr. Pirozzi
15233 Ventura Blvd, Suite #1208
Sherman Oaks, CA 91403
Estimate of what you could pay
Refine Psychiatry
- Child/Adolescent Initial Evaluation (CPT Code 90792): $800
- Adult Initial Evaluation (CPT Code 90792): $600
- Medication Management appointments (CPT Code 99213, 99214, 99215): $275
- Psychotherapy (CPT code 90833, 90836): $325
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.
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.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 800-985-3059.
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.