Good Faith Estimate (GFE) & No Surprises Act Disclosure

Applicable to: Prevail Behavioral Health & Wellness Center | NPI: 1326488073 | TIN (Counseling): 46-2057056

Prevail Assessment & Wellness, P.C.  |  TIN (Assessment): 83-2092410

Service Location: 620 Longmire Rd., Conroe, TX 77304 or 1325 Windsor St., Huntsville, TX 77340


1. Understanding Your Estimate

This Good Faith Estimate (GFE) is provided to all uninsured and self-pay clients, as well as those using insurance. While we verify insurance as a courtesy, quotes are not a guarantee of payment. If your insurance denies a claim or applies it to a deductible, you are responsible for the rates listed below.

Initial Diagnosis: All new patients are assigned a placeholder diagnosis of F99 (Unspecified Mental Disorder) until a formal evaluation is completed.
Duration of Estimate: This GFE is valid for 12 months from the date of issue.

2. Standard Service Fee Schedule

These rates represent the "Standard Private Pay" cost for services. If you are using insurance, your actual out-of-pocket will depend on your negotiated rate and deductible.

Service Description CPT / HCPCS Code Standard Rate
New Patient Intake (Counseling) 90791 + 90785 $230
New Patient Intake (Psychiatry/Med) 99204 + 90833 $450
Med Management + Longitudinal Care 99214 + 90833 + G2211 $330
Individual Therapy (53+ min) 90837 + 90785 $215
Crisis Intervention (First 60 min) 90839 $200
Crisis Intervention (Add-on 30 min) 90840 $100
BHI Care Integration (Per Month) 99484 / G0323 $100
Forensic Services Retainer Retainer Fee $5,000

3. Psychological Assessment Fees (Prevail Assessment & Wellness, P.C.)

Testing administration is performed through Prevail Assessment & Wellness and is not contracted with insurance. These are Private Pay only.

We utilize a Phased Testing Model to ensure cost-efficiency.

Phase 1: Standard Clinical Screening: $450 (Includes ADHD/Clinical Syndromes/Personality)
Phase 2: Specialty Add-ons: +$150 – $3,600 (Autism, Intellectual Disability, or Neuro-evaluations)
Phase 3: Final Report & Feedback: $200 (CPT 96130)
Total Assessment Range: Most cases range from $550 to $3,800 total.

4. Estimated Annual "Course of Care" Totals (Prevail Behavioral Health & Wellness Center)

The ranges below reflect a high-end annual estimate for patients with complex needs, including Schedule II medication management (monthly follow-ups) and regular therapy.

Treatment Track Expected Frequency Estimated Annual Total
Complex Med Management Monthly Visits + BHI $3,960 – $8,160
Standard Med Management Quarterly Visits + BHI $1,320 – $5,400
Intensive Counseling Weekly + 2 Crisis Sessions $11,580 – $12,000
Maintenance Counseling Bi-Weekly / Monthly $2,160 – $8,160
Diagnostic Evaluation One-time Series (4 Phases) $550 – $1,700

5. Why your actual bill may be lower:

Insurance Coverage: If you have met your deductible, your co-pay may be as low as $20–$50 per session.
Clinical Stabilization: As you reach your goals, we decrease frequency (e.g., moving from weekly to monthly).
Selective Testing: We stop testing as soon as a definitive diagnosis is reached, avoiding unnecessary "Phase 2" costs.

6. Legal Disclaimers (No Surprises Act)

The Right to Dispute: This estimate shows costs that are reasonably expected for your healthcare needs. It does not include unknown or unexpected costs (e.g., an unexpected crisis). If you are billed for $400 or more than this GFE, federal law allows you to dispute the bill.

Dispute Timeline: You must start the dispute process within 120 calendar days of the original bill. Visit www.cms.gov/nosurprises or call 1-800-985-3059 for more info.

NO SURPRISE ACT NOTICE
YOUR RIGHT TO A “GOOD FAITH ESTIMATE”