NOTICE REGARDING HEALTH CARE PLAN COVERAGE

This freestanding emergency department (Belmar Emergency Department ) accepts patients enrolled in the following programs: Colorado Medicaid (Articles 4, 5 and 6 of Title 25.5); Medicare (Title XVIII of the Federal Social Security Act, as amended); the CHIP program (Article 8 of Title 25.5) and a military health plan (10 U.S.C. Section 1071).

The prices listed on this facility’s chargemaster or fee schedule for any given health care service is the maximum charge that any patient will be billed for the service.  The actual price for the health care service may be lower depending on your health insurance benefits and the availability of discounts or financial assistance.

This Facility will charge a facility fee with prices ranging approximately and, on average, from $559 to $10,659. In addition to these fees you will be charged for any testing, supplies, or other services you receive. All physicians providing health care services will bill separately from the Facility for services they provided to you.

The health care provider networks and carriers that this Facility participates with are listed on the attached Exhibit 1.

This Facility and/or a physician providing health care services may not be a participating provider in your health insurance provider network.

If you are covered by health insurance, you are strongly encouraged to consult with your health insurer to determine accurate information about your financial responsibility for a particular health care service provided at this Facility. If you are not covered by health insurance, you are strongly encouraged to contact (866) 475-1385 to discuss payment options and the availability of financial assistance prior to receiving a health care service from this Facility.

The average fee schedule price for the twenty-five most common health care services provided by this Facility are listed on the attached Exhibit 2. The prices listed for each health care service is the average charge that you may be billed for the particular service. The actual price for the health care service may be lower depending on your insurance coverage and the availability of discounts or financial assistance.

Belmar Emergency Department

Charge DescriptionAverage Charge per Account
Complete blood count lab test $181
Catheter (needle) used to start an IV $10
Single or first dose of medication delivered via IV $426
1000ml bag of saline IV fluids $597
Complete panel of 14 blood tests $612
Urine test conducted via machine with microscope $266
Blood test for pancreatic enzymes $397
Each additional hour of IV fluid hydration $495
Blood test for pregnancy $255
Second or each additional dose of medication delivered via IV $660
Basic panel of 7 or 8 blood tests, including total calcium $482
External recording of the electrical activity of the heart $711
30mg injection of Ketorolac, a non-steroidal anti-inflammatory medication $20
ED PROC CAT 2 $1,973
4mg vial of Ondansetron, used to prevent nausea and vomiting $200
Chest x-ray with 1 view $852
Ibuprofen 600mg tablet $4
Blood test for the heart muscle $616
Rapid strep test to diagnose strep throat $104
Intramuscular or subcutaneous injection $279
Acetaminophen 500mg tablet $8
Chest x-ray with 2 views $947
Urine test conducted via machine without microscope $174
4mg oral dose of Ondansetron, used to prevent nausea and vomiting $10
Culture for group A strep $311

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NOTICE REGARDING HEALTH CARE PLAN COVERAGE

This freestanding emergency department (Southwest Emergency Department ) accepts patients enrolled in the following programs: Colorado Medicaid (Articles 4, 5 and 6 of Title 25.5); Medicare (Title XVIII of the Federal Social Security Act, as amended); the CHIP program (Article 8 of Title 25.5) and a military health plan (10 U.S.C. Section 1071).

The prices listed on this facility’s chargemaster or fee schedule for any given health care service is the maximum charge that any patient will be billed for the service.  The actual price for the health care service may be lower depending on your health insurance benefits and the availability of discounts or financial assistance.

This Facility will charge a facility fee with prices ranging approximately and, on average, from $511 to $10,311. In addition to these fees you will be charged for any testing, supplies, or other services you receive. All physicians providing health care services will bill separately from the Facility for services they provided to you.

The health care provider networks and carriers that this Facility participates with are listed on the attached Exhibit 1.

This Facility and/or a physician providing health care services may not be a participating provider in your health insurance provider network.

If you are covered by health insurance, you are strongly encouraged to consult with your health insurer to determine accurate information about your financial responsibility for a particular health care service provided at this Facility. If you are not covered by health insurance, you are strongly encouraged to contact (866) 475-1385 to discuss payment options and the availability of financial assistance prior to receiving a health care service from this Facility.

The average fee schedule price for the twenty-five most common health care services provided by this Facility are listed on the attached Exhibit 2. The prices listed for each health care service is the average charge that you may be billed for the particular service. The actual price for the health care service may be lower depending on your insurance coverage and the availability of discounts or financial assistance.

Southwest Emergency Department

Charge DescriptionAverage Charge per Account
Complete blood count lab test $195
1000ml bag of saline IV fluids $583
Catheter (needle) used to start an IV $10
Single or first dose of medication delivered via IV $469
Complete panel of 14 blood tests $663
External recording of the electrical activity of the heart $701
Blood test for pancreatic enzymes $431
Basic panel of 7 or 8 blood tests, including total calcium $514
Each additional hour of IV fluid hydration $637
Blood test for the heart muscle $680
Second or each additional dose of medication delivered via IV $699
Urine test conducted via machine with microscope $291
Chest x-ray with 1 view $835
Blood test for pregnancy $272
30mg injection of Ketorolac, a non-steroidal anti-inflammatory medication $20
4mg vial of Ondansetron, used to prevent nausea and vomiting  $188
ED PROC CAT 2 $2,174
Low osmolar contrast material used in diagnostic radiology  $1,400
Urine test conducted via machine without microscope $190
Ibuprofen 600mg tablet $4
25mg injection of Promethazine, to treat allergies, motion sickness, pain, nausea, vomiting $17
Acetaminophen 500mg tablet  $8
Computerized tomography "Cat Scan" of the abdomen and pelvis with contrast $8,906
Definitive drug tests for 1-7 classes including metabolites $1,146
700mg 5% Lidocaine patch $59

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Contracted Plans

PlanCommercial Group and IndividualManaged MedicareManaged Medicaid
AETNA (Inc. Coventry and FirstHealth) All Networks All Networks N/A
Anthem BCBS All Networks (excluding Mountain Enhanced) All Networks (Excluding PPO) N/A
BrightHealth All Networks (Emergency Only) Not participating N/A
CIGNA All Networks N/A N/A
Clear Spring N/A All Networks N/A
Colorado Access N/A N/A All Networks
Humana Not participating All Networks N/A
InnoVage N/A All Networks N/A
Kaiser All Networks (Swedish ER and Belmar Locations only) All Networks and locations N/A
Multiplan/PHCS All Hospital Networks (excluding physician only networks) N/A N/A
Rocky Mountain Health Plan All Networks N/A All Networks
UnitedHealthcare All Networks (except Colorado Doctors Plan) All Networks N/A