No Surprises Act Compliance

Effective Date: June 1, 2022
Last Updated: October 1, 2026

The No Surprises Act is a federal law about medical bills. This page explains what it means for your care with Envisioning Wellness LLC, in plain words. We follow the parts of the law that apply to our services, and we want you to know what your care will cost before you start.

1. Good Faith Estimate for self-pay and uninsured clients

If you do not have insurance, or you choose not to use it, you have the right to a Good Faith Estimate. It shows the expected cost of your non-emergency mental health care before you begin.

Your estimate will show:

  1. The session fee.

  2. Any assessment or evaluation fee.

  3. How often we expect to meet, and for how long.

  4. The total expected cost for the period it covers.

When you will get it, in writing:

  1. If you schedule an appointment 10 or more business days ahead: within 3 business days after you schedule.

  2. If you schedule an appointment 3 to 9 business days ahead: within 1 business day after you schedule.

  3. If you ask for an estimate without scheduling: within 3 business days after you ask.

  4. If you schedule less than 3 business days ahead, we will give you the estimate before your first session whenever we can.

The estimate is not a contract. You do not have to use our services after you receive it. If your care plan changes, we will give you an updated estimate in writing before the change takes effect, whenever we can.

You can ask for an estimate at any time. Keep a copy to compare with your bills.

2. If your bill is much higher than your estimate

If a bill is at least $400 more than your Good Faith Estimate, you can use a federal dispute process. You must start it within 120 calendar days of the date on the bill. Keep your estimate and your bill. Contact us first. We will review the bill with you. You can also go to www.cms.gov/nosurprises or call 1-800-985-3059.

3. If you have insurance

What we do for insured clients is our own practice policy. It is not a Good Faith Estimate under federal law.

Before your first session we will:

  1. Tell you whether we are in network or out of network with your plan.

  2. Explain the fee you will owe.

  3. Help you understand your benefits if you ask.

  4. Help you find an in-network provider if you ask.

Our current network status:

Insurance company:

Aetna, Blue Cross Blue Shield, Cigna, HealthPartners, Medica, Optum, UnitedHealthcare, UMR

Minnesota: In network for eligible therapy services

UnitedHealthcare, Optum, UMR, Medica (including Dean Health Plan)

Wisconsin

Anthem Blue Cross Blue Shield (through Carelon)

UnitedHealthcare (including Oxford)

New Jersey

UnitedHealthcare, Optum, UMR, Medica

Washington

No plans in network

North Dakota, Texas

Out of network

Status as of October 1, 2026. Please confirm with us before your first session.

  1. In network means we have a contract with the plan for the state shown.

  2. Pending means our contract is not complete. Please treat us as out of network until we confirm in writing that we are in network with your plan.

  3. These are commercial plans. Medicaid plans are not included.

  4. If your plan is not listed, we are out of network with it.

If we are out of network with your plan:

  1. You may owe more than you would owe an in-network provider.

  2. Your plan may pay less, or may pay nothing.

  3. Payments may not count toward your in-network deductible or out-of-pocket limit.

  4. We can give you a superbill (a receipt with billing codes) to send to your plan for possible reimbursement. Your plan decides what it pays.

4. Balance billing protections: what they cover

Balance billing means a provider bills you for the difference between its charge and what your plan pays. The No Surprises Act protects you from it in certain cases. These include emergency care and some care from out-of-network providers at in-network hospitals and surgical centers.

These protections generally do not cover outpatient therapy from an out-of-network private practice like ours. If we are out of network with your plan, you may owe our full fee. We will tell you our fee before your first session.

5. Your state

Your state may give you more protection. Contact your state insurance regulator:

Minnesota

Minnesota Department of Commerce, Insurance Division

651-539-1500 (complaints); 800-657-3602 (Greater Minnesota)

Wisconsin

Office of the Commissioner of Insurance

800-236-8517 (in Wisconsin); 608-266-0103 (outside Wisconsin)

North Dakota

Insurance Department

701-328-2440 7

Washington

Office of the Insurance Commissioner

1-800-562-6900

New Jersey

New Jersey Department of Banking and Insurance

(609) 292-7272

Texas

Texas Department of Insurance

800-578-4677; balance-billing questions: IDR@tdi.texas.gov

6. Fees and payment

  1. We will tell you our fees before services begin.

  2. We will give at least 30 days' written notice before a fee change.

  3. We can talk about payment plans when they are a good fit.

  4. Clients receive our cancellation policy in their intake documents in the client portal. Our fees are listed at envisioningwellness.com/fees.

7. Questions, complaints and reports

Ask about an estimate or a bill

Phone (952) 314-8364, email dorothee@envisioningwellness.com

Dispute a bill or report a problem at the federal level

www.cms.gov/nosurprises or 1-800-985-3059

Report a problem at the state level

The agency for your state in section 5

8. Accessible formats and languages

This notice is available in other formats and languages on request. Call or email us and we will provide it.

Key terms

  1. Good Faith Estimate: a written estimate of the expected cost of scheduled care.

  2. Balance billing: a bill for the difference between a provider's charge and the amount your plan pays.

  3. Out of network: the provider has no contract with your plan.

  4. Cost-sharing: your part of the cost, such as copays, coinsurance and deductibles.

  5. Self-pay: you pay for services yourself and do not use insurance.

Envisioning Wellness LLC
Dorothee Tshiela, MA, LPCC
3470 Washington Drive, Suite 216, Eagan, MN 55122
Phone: (952) 314-8364

This notice reflects the No Surprises Act (Public Law 116-260, Division BB, Title I). For current information, visit www.cms.gov/nosurprises

How We Help You

Transparency Commitment

Envisioning Wellness LLC is committed to:

  • Clear Communication: Explaining all costs before services begin

  • Written Estimates: Providing Good Faith Estimates in writing

  • Insurance Verification: Helping verify your benefits before treatment

  • Payment Options: Discussing payment arrangements when needed

Before Your First Appointment

We will:

  1. Verify your insurance coverage (if applicable)

  2. Explain whether we are in-network or out-of-network

  3. Provide a Good Faith Estimate of costs

  4. Answer any questions about fees or billing

  5. Discuss payment options if needed

Ongoing Treatment

For continuing care, we will:

  • Update your Good Faith Estimate if treatment plans change

  • Notify you of any fee changes with adequate notice

  • Provide regular statements showing services and costs

  • Work with you if financial circumstances change

Your Options

If We Are Out-of-Network

You always have choices:

  1. Continue with Our Services: Understanding the out-of-network costs

  2. Request In-Network Referrals: We can help you find in-network providers

  3. Submit for Reimbursement: We provide documentation for insurance claims

  4. Negotiate with Insurance: Your plan may agree to cover services at in-network rates

Payment Arrangements

We offer:

  • Transparent fee schedules

  • Payment plans when appropriate

  • Superbills for insurance reimbursement

  • Discussion of treatment frequency to manage costs

How to Get Help

Questions About Your Estimate or Bill

Contact Our Office:

  • Phone: (952) 314-8364

  • Email: dorothee@envisioningwellness.com

  • Secure Portal: Available for confidential communications

To Dispute a Bill

If your bill exceeds your Good Faith Estimate by $400 or more:

  1. Contact Us First: We'll review and explain any discrepancies

  2. Federal Dispute Process: Visit www.cms.gov/nosurprises

  3. Call the Help Desk: 1-800-985-3059

To Report Violations

Federal Resources:

State Resources:

  • Minnesota: Department of Commerce (651-539-1500)

  • Wisconsin: Office of the Commissioner of Insurance (608-266-3585)

  • North Dakota: Insurance Department (701-328-2440)

  • Washington: Office of the Insurance Commissioner (1-800-562-6900)

Key Terms Explained

Good Faith Estimate: A written estimate of the expected charges for scheduled services

Balance Billing: Being billed for the difference between the provider's charge and the insurance payment

Out-of-Network: Providers who haven't contracted with your insurance plan

Cost-Sharing: Your portion of costs (copayments, coinsurance, deductibles)

Self-Pay/Uninsured: Paying for services without using insurance benefits

Our Commitment

Envisioning Wellness LLC is committed to:

  • Full compliance with the No Surprises Act

  • Transparent and ethical billing practices

  • Clear communication about all costs

  • Supporting our clients in understanding their financial responsibilities

  • Providing quality mental health services with no financial surprises

Contact Information

Envisioning Wellness LLC
Dorothee Tshiela, MA, LPCC
3470 Washington Drive, Suite 216
Eagan, MN 55122

Phone: (952) 314-8364
Fax: (952) 213-6042

Office Hours: By appointment
Good Faith Estimates: Available upon request and during scheduling

This notice is provided in compliance with federal requirements under the No Surprises Act (H.R.133). For the most current information about your rights, visit www.cms.gov/nosurprises.