NOTICE REGARDING HEALTH CARE PLAN COVERAGE

7/1/2020

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 Description Average Charge per Account

Single or first dose of medication IV

$464

1000 ML bag of saline IV fluid

$670

Catheter needle used to start IV

$12

Complete panel of 14 blood tests

$660

Each additional hour of IV fluid hydration

$545

Blood test for pancreatic enzymes

$431

Urine test conducted via machine with micro

$297

Second or each additional dose delivered IV

$656

Basic panel of 7 or 8 blood tests including CA

$532

Blood test for pregnancy

$280

Chest XRAY 1 view

$994

15mg injection of Ketorolac, a non-steroid anti-inflammatory medication

$22

4mg vial of Ondansetron, used to prevent nausea and vomiting

$215

External recording of electrical activity of heart

$792

Blood test for heart muscle

$656

Urine test without microscope

$192

IBUPROFEN 600MG TAB

$5

Low osmolar contrast material used in diagnostic radiology

$1,067

Rapid stress test to diagnose strep throat

$112

Chest X-Ray with 2 views

$1,101

Acetaminophen 500 mg tablet

$9

ED PROC CAT 2

$2,154

Intramuscular subcutaneous injection

$297

Culture for group A strep

$333

ED PROC CAT 1

$425

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NOTICE REGARDING HEALTH CARE PLAN COVERAGE

7/1/2020

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 $211
1000ml bag of saline IV fluids $633
Catheter (needle) used to start an IV $11
Single or first dose of medication delivered via IV $504
Complete panel of 14 blood tests $704
External recording of the electrical activity of the heart $775
Blood test for pancreatic enzymes $466
Basic panel of 7 or 8 blood tests, including total calcium $586
Each additional hour of IV fluid hydration $619
Blood test for the heart muscle $742
Second or each additional dose of medication delivered via IV $733
Urine test conducted via machine with microscope $316
Chest x-ray with 1 view $954
Blood test for pregnancy $307
15mg injection of Ketorolac, a non-steroidal anti-inflammatory medication $21
4mg vial of Ondansetron, used to prevent nausea and vomiting $208
ED PROC CAT 2 $1,348
Low osmolar contrast material used in diagnostic radiology $1,516
Urine test conducted via machine without microscope $206
Intramuscular subcutaneous injection $325
CT of head/brain w/out contrast $4,797
Acetaminophen 500mg tablet $9
Computerized tomography "Cat Scan" of the abdomen and pelvis with contrast $9,829
Definitive drug tests for 1-7 classes including metabolites $1,113
700mg 5% Lidocaine patch $62

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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 All Networks N/A
BrightHealth All Networks (Emergency Only) Not participating N/A
CIGNA All Networks All Networks N/A
Clear Spring N/A All Networks N/A
Colorado Access N/A N/A All Networks
Friday Health Plan Not Participating N/A N/A
Humana Not participating All Networks N/A
InnoVage N/A All Networks N/A
Kaiser All Networks (All FSED Locations only) All Networks and locations N/A
Multiplan/PHCS All Hospital Networks (excluding physician only networks) N/A N/A
Mutual of Omaha N/A All Networks N/A
OSCAR All Networks N/A N/A
Rocky Mountain Health Plan All Networks All Networks All Networks
UnitedHealthcare All Networks (except Colorado Doctors Plan) All Networks N/A