NOTICE REGARDING HEALTH CARE PLAN COVERAGE

6/1/2019

This freestanding emergency department (Northeast 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 $663 to $7,457. 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) 475-2403 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.

Northeast Emergency Department

Charge DescriptionAverage Charge per Account
Complete blood count lab test $473
Single or first does of medication delivered via IV $337
1000ml bag of saline IV fluids $357
Catheter (needle) used to start an IV $15
Complete panel of 14 blood tests $1,231
IV tubing $34
Basic panel of 7 or 8 blood tests, including calcium $743
Each additional hour of IV fluid hydration $200
External recording of the electrical activity of the heart $1,314
Blood test for pancreatic enzymes $478
Second or each additional dose of medication delivered via IV $523
30 mg injection of Ketorolac, non-steroidal anti-inflammatory medication $81
Urine test conduction via machine with microscope $344
4 mg vial of Ondansetron, used to prevent nausea and vomiting $343
Chest x-ray with two views $1,052
Urine test conduction via machine without microscope $286
Blood test for pregnancy $553
Blood test for the heart muscle $801
Urine pregnancy test $545
Low osmolar contrast material used in diagnostic radiology  $770
Definitive drug tests for 1-7 classes including metabolites $692
Rapid stress test to diagnose strep throat $384
Chest x-ray with one view $620
Culture for group A strep $328
ED PROC CAT 2 $1,861

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NOTICE REGARDING HEALTH CARE PLAN COVERAGE

6/1/2019

This freestanding emergency department (Northwest 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 $666 to $7,711. 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) 475-2403 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.

Northwest Emergency Department

Charge DescriptionAverage Charge per Account
Complete blood count lab test $472
Basic panel of 7 or 8 blood tests, with ionized calcium $727
1000ml bag of saline IV fluids $356
Single or first dose of medication delivered via IV $342
External recording of the electrical activity of the heart $1,376
Catheter (needle) used to start an IV $16
Complete panel of 14 blood tests $1,194
Each additional hour of IV hydration $214
IV tubing $35
30mg injection of Ketorolac, a non-sterodial anti-inflammatory medication $83
Second or each additional dose of medication delivered via IV $491
Urine pregnancy test $543
Blood test for the heart muscle $796
4mg vial of Ondansetron, used to prevent nausea and vomitting $343
Blood test for pancreatic enzymes $466
Urine test conducted via machine with microscope $336
Chest x-ray with two views $1,058
Definitive drug tests for 1-7 classes including metabolites $682
ED PROC CAT 2 $1,849
Urine test conducted via machine without microscope $286
Rapid strep test to diagnose strep throat $352
IBUPROFEN 600MG TAB $20
Chest x-ray with one view $609
Injection of medication or vaccine given intramuscular or subcutaneous $380
Culture for group A strep $325

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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