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 $490
Catheter needle used to start IV $16
Tubing used for IV $36
Single or first dose of medication IV $373
1000 ML bag of saline IV fluid $383
Complete panel of 14 blood tests $1,276
Each additional hour of IV fluid hydration $221
Urine test conducted via machine with microscope $349
Basic panel of 7 or 8 blood tests including CA $787
30mg injection of Ketorolac, a non-steroid anti-inflammatory medication $85
External recording of electrical activity of heart $1,407
Blood test for pancreatic enzymes $473
4mg vial of Ondansetron, used to prevent nausea and vomiting $364
Urine pregnancy test $564
Second or each additional dose delivered IV $496
Urine test without microscope $298
ED PROC CAT 1 $768
Blood test for heart muscle $809
Rapid stress test to diagnose strep throat $407
Low osmolar contrast material used in diagnostic radiology $853
Culture for group A strep $327
Chest x-ray with two views $1,171
Normal Saline 500ml $208
Chest x-ray with one view $688
Acetaminophen 500mg tablet $5

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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 $505
Single of first dose of medication delivered via IV $352
1000ml bag of saline IV fluids $365
Basic panel of 7 or 8 blood tests, with ionized calcium $768
30mg injection of Ketorolac, a non-steroid anti-inflammatory medication $90
Each additional hour of IV hydration $265
4mg vial of Ondansetron, used to prevent nausea and vomiting $354
Second or each additional dose of medication delivered via IV $533
Injection of medication or vaccine given intramuscular or subcutaneous $486
Complete panel of 14 blood tests $1,311
Catheter needle used to start IV $17
ED PROC CAT 1 $768
Blood test for pancreatic enzymes $510
Urine pregnancy test $591
External recording of the electrical activity of the heart $1,483
Chest x-ray with one view $688
IBUPROFEN 600MG TAB $20
Low osmolar contrast material used in diagnostic radiology $822
Chest x-ray with two views $1,171
Blood test for heart muscle $809
4 mg oral dose of Ondansetron $7
Culture for group A strep $348
Tdap vaccination administered intramuscular for children 7 years of age $423
Rapid stress test to diagnose strep throat $407
Administration of a single immunization $341

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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