Good Faith Estimate
Heal Good Good, LLC Faith Estimate
Notice Required Under the No Surprises Act (45 CFR §149.610)
You have the right to receive a Good Faith Estimate explaining how much your healthcare will cost. Under
the No Surprises Act, health care providers must give patients who are uninsured or who are not using
insurance an estimate of expected charges before providing services. This Good Faith Estimate is not a
contract and does not require you to obtain services from Heal Good, LLC.
About This Estimate
This Good Faith Estimate applies to self-pay clients and clients who choose not to use their insurance
benefits for therapy services with Heal Good, operated by Shenay Brown, LICSW, in the
Commonwealth of Massachusetts.
This estimate is based on the information available at the time it is provided. Actual costs may vary
depending on the nature, frequency, and duration of services, which will be determined collaboratively
based on your clinical needs and treatment goals.
Provider Information
Practice Name: Heal Good
Clinician: Shenay Brown, LICSW
License: Licensed Independent Clinical Social Worker — Massachusetts
NPI Number: 1639592058
Address: Telehealth Services — Massachusetts
Phone: 617-380-3173
Email: Hello@healgoodbos.com
Services and Fee Schedule
The following rates apply to self-pay services. These fees reflect the full cost of services when
insurance is not being billed.
Service CPT Code Duration Rate Per SessionInitial Intake / Clinical
Evaluation 90791 60 min $250.00
Individual Therapy (Standard
Session) 90837 50–55 min $175.00
Individual Therapy (45-min
Session) 90834 45 min $175.00
Note: Session length and CPT code used may vary based on clinical need and mutual agreement. The
90834 and 90837 codes reflect the same self-pay rate of $175 per session. The appropriate code will be
selected based on actual session duration.
Estimated Cost of Services
The length of treatment varies by individual. The following estimates are provided based on weekly
sessions, which is the standard frequency recommended for most clients at the start of treatment.
These are estimates only — your actual treatment duration will be determined collaboratively with your
clinician.
Scenario Sessions Estimated Annual Cost
Intake + 12 weeks weekly therapy 13 sessions $2,350.00
Intake + 24 weeks weekly therapy 25 sessions $4,500.00
Intake + 48 weeks weekly therapy (full year) 49 sessions $8,800.00
These estimates include one intake session (CPT 90791 at $250) plus ongoing individual therapy sessions
(CPT 90837 at $175 each). Actual totals may be higher or lower depending on treatment length, frequency
changes, or additional services.
Payment Information
Payment is due at the time of service. Accepted payment methods include:
• Credit or debit card (Visa, Mastercard, American Express, Discover)
• HSA/FSA cards• Other payment methods as agreed upon during intake
A cancellation policy is in effect. Sessions cancelled with less than 24 hours’ notice may be subject to a
late cancellation fee. Please refer to your signed consent to treatment agreement for full details.
Insurance
Heal Good is currently in-network with the following insurance plans:
• Blue Cross Blue Shield (BCBS) Massachusetts
• Harvard Pilgrim Health Care / Point32Health
• Tufts Health Plan
• UBH / Optum
If you are using insurance, this Good Faith Estimate may not reflect your actual out-of-pocket costs,
which will depend on your specific plan, deductible, copay, and coinsurance. It is your responsibility to
verify your mental health benefits prior to your first appointment. We recommend contacting your
insurance company directly to confirm your coverage.
Your Rights Under the No Surprises Act
As a patient, you have the following rights:
• You have the right to receive a Good Faith Estimate for the total expected cost of any
non-emergency healthcare items or services upon request or when scheduling care.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to
dispute the bill.
• You may contact the provider to let them know the billed charges are higher than the Good Faith
Estimate and ask them to update the bill to match the 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 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 the 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 or get a form to start the process, go to www.cms.gov/nosurprises or call
1-800-985-3059.
Questions or ConcernsIf you have questions about this Good Faith Estimate or your bill, please contact us before seeking
dispute resolution:
Heal Good, LLC
Shenay Brown, LICSW
Phone:617-380-3173
Email: Helllo@healgoodbos.com
Heal Good, LLC • Massachusetts • healgoodbos.com