United Behavioral Health
Blue Cross Blue Shield PPO
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 both orally and in writing, upon request or at the time of scheduling health care items and services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
You have a right to initiate a patient-provider dispute resolution process if the actual billed charges substantially exceed the expected charges included in the good faith estimate. Initiation of a dispute resolution process will not adversely affect the quality of health care services provided to you. To initiate a dispute resolution please visit www.cms.gov/nosurprises or contact Melanie Wall at 224-326-4200 or by email at firstname.lastname@example.org.