Effective Date: October 1, 2026

 

Under the federal No Surprises Act, you generally have the right to receive a “Good Faith Estimate” explaining how much your health care is expected to cost if you do not have health insurance or if you have health insurance but do not intend to have a claim submitted to your health plan for your care. These individuals are referred to as “uninsured” or “self-pay” individuals.

 

YOUR RIGHT TO A GOOD FAITH ESTIMATE

If you are uninsured or self-pay, you have the right to receive a Good Faith Estimate of the expected charges for health care items or services you schedule with Mensana Collaborative or request information about before scheduling.

 

A Good Faith Estimate is not a bill. It is an estimate, based on information known at the time the estimate is prepared, of the charges reasonably expected for your care. Actual services or charges may differ if your treatment needs or circumstances change.

 

WHEN YOU WILL RECEIVE A GOOD FAITH ESTIMATE

If you schedule an item or service at least 3 business days in advance, Mensana Collaborative will provide a Good Faith Estimate within the time required by federal law:

• If you schedule care 3 to 9 business days in advance, the Good Faith Estimate will be provided within 1 business day after scheduling.

• If you schedule care 10 or more business days in advance, the Good Faith Estimate will be provided within 3 business days after scheduling.

• You may also request a Good Faith Estimate before scheduling care. If you do, Mensana Collaborative will provide the estimate within 3 business days after your request.

 

If care is scheduled fewer than 3 business days in advance, federal law does not require a Good Faith Estimate to be provided before the scheduled service.

 

WHAT YOUR GOOD FAITH ESTIMATE INCLUDES

Your Good Faith Estimate will identify the items or services that Mensana Collaborative reasonably expects to provide and the expected charges for those items or services.

 

For recurring services, such as ongoing psychotherapy or medication-management appointments, a Good Faith Estimate may cover an anticipated course of care for up to 12 months. If additional recurring services are expected beyond the period covered by the estimate, a new Good Faith Estimate may be provided.

 

A Good Faith Estimate from Mensana Collaborative generally reflects only the items and services expected to be provided by Mensana Collaborative. It may not include services that are separately scheduled or provided by other health care providers or facilities.

 

CHANGES IN YOUR CARE

A Good Faith Estimate is based on the information reasonably known when the estimate is prepared and does not guarantee the exact services you will need or the exact amount you will ultimately be charged.

 

Your treatment needs may change over time. Changes in the type, frequency, or duration of services you receive may result in charges that differ from your original Good Faith Estimate. When appropriate or required, Mensana Collaborative may provide an updated Good Faith Estimate reflecting changes in your anticipated care.

 

IF YOUR BILL IS $400 OR MORE ABOVE YOUR ESTIMATE

If you receive a bill from a provider or facility that is at least $400 more than the amount listed for that provider or facility on your Good Faith Estimate, you may be eligible to dispute the bill through the federal Patient-Provider Dispute Resolution process.

 

You generally must begin the dispute process within 120 calendar days of the date on the initial bill. An independent third party will review the Good Faith Estimate, the bill, and other relevant information and determine the appropriate amount to be paid.

 

Keep a copy of your Good Faith Estimate so that you can compare it with bills you receive.

 

QUESTIONS OR MORE INFORMATION

If you have questions about a Good Faith Estimate from Mensana Collaborative, please contact:

 

Mensana Collaborative
3771 Rio Rd, Suite 111
Carmel, CA 93923
831.293.7300
contact@mensanacollab.com

 

For additional information about your rights under the No Surprises Act or the Patient-Provider Dispute Resolution process, contact the No Surprises Help Desk at 1-800-985-3059 or visit the Centers for Medicare & Medicaid Services' Medical Bill Rights resources.