Patient Price Information List
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- Kathryn Chandler
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1 Patient Price Information List In compliance with state law, The Christ Hospital is providing this price list containing our charges for room and board, emergency department, operating room, delivery, physical therapy and other procedures. The hospital's charges are the same for all patients, but a patient's responsibility may vary, depending on payment plans negotiated with individual health insurers. Uninsured or underinsured patients should consult with our admitting and billing staff to determine whether they qualify for discounts. These prices are correct as of 7/01/18. Room and Board -- Per Day made by a hospital for the room, routine nursing services, routine supplies, and meals for a person confined as a bed patient. Room and board charges can be defined as private or semi-private. Private Med/Surg Room $1, Labor & Delivery $1, Psych/Chem Dependency $1, Rehab $1, Stepdown - Cardiac $2, Medical ICU $6, Surgical ICU $6, Cardiac ICU $6, Newborn - Normal $1, Newborn Continuing Care $1, Newborn Intermediate $4, Observation Observation status is used for evaluating a patient to determine the need for treatment as an inpatient admission, or for observing a patient due to a complication following a procedure Observation Private Initial Hour $1, Ea Additional Hr $22.00
2 Labor and Delivery The following list does not include charges for drugs, or non-routine supplies required for a particular delivery room procedure. Fees for physician services or anesthesia administration are also not reflected, and will be billed separately by your physician. Vaginal Delivery $6, Cesarean Section Delivery $8, Fetal Non-Stress Test $ Emergency Department Emergency Department charges are based on the level of emergency care provided to our patients. The levels, with level 1 representing basic emergency care, reflect the type of accommodations needed, the personnel resources, the intensity of care and the amount of time needed to provide treatment. The following charges do not include fees for drugs, supplies or additional ancillary procedures that may be required for a particular emergency treatment. They also do not include fees for Emergency Department physicians, who will bill separately for their services. Level 1 $ Level 2 $ Level 3 $1, Level 4 $1, Level 5 $3, Critical care $4, Operating Room Operating Room charges are based on the complexity level, with "Minor" being the most basic, for a particular operation. There is an initial charge as well as an additional charge for each minute beyond the first 30 minutes while the operation is being performed. Initial 30 minutes Additional minutes Minor $4, Major $5, $ Complex $5, $133.00
3 Physical Therapy The following charges reflect the most common services offered by our Physical Therapy department. Patients may have additional charges, depending on the services performed. PT Evaluation Low Complexity $ PT Gait Training (15 minutes) $ PT Ultrasound/Phonophoresis (15 Minutes) $ PT Manual Therapy/Mobiliziation (15 Minutes) $ PT Therapeutic Activities - (15 Minutes) $ PT Therapeutic Exercise (15 Minutes) $ Occupational Therapy The following charges reflect the most common services offered by our Occupational Therapy department. Patients may have additional charges, depending on the services performed. OT Evaluation Low Complexity $ OT Re-Eval $ OT Therapeutic Activities (15 Minutes) $ OT Self Care/ADL (15 Minutes) $ OT Therapeutic Exercise (15 Minutes) $ OT Group Therapeutic Procedures $ Pulmonary Therapy Respiratory Therapy focuses on exercises and treatments that help preserve, improve, or restore lung function. The following charges reflect the most common services offered by our Pulmonary Therapy department. Patients may have additional charges, depending on the services performed. Ventilator - Assist and Manage - Initial $1, Oximetry Continuous $ Pulmonary Exercise/Oximetry Simple $230.00
4 X-Ray and Radiological The following charges include the hospital's 30 most common x-ray and radiological procedures. Some radiologic procedures include the use of a contrast agent to better visualize anatomy and may represent an additional charge. IP CHARGE OP CHARGE MRI- Head (with and without contrast) $3,757 $3,167 MRI- L Spine (without contrast) $2,678 $2,068 CT - Abdomen & Pelvis (with contrast) $5,111 $4,691 CT - Abdomen & Pelvis (without contrast) $4,597 $4,219 CT- Head (without contrast) $1,378 $1,153 CT- Thorax (w/o contrast) $1,575 $1,153 CT- Chest (with contrast) $1,917 $1,757 US- Transvaginal $758 $575 US- Abdomen (limited) $650 $575 US-Abdominal, Real Time w Image documentation,compl $794 $575 US-Retroperitoneal Real Time w Image documentation,com $834 $765 US- Head/Neck Tissues, B-Scan/Real time $627 $575 US- Breast Unilateral Inc Axilla $526 $377 Mammography Direct Digital Screening $299 $257 Mammography Direct Digital Diagnostic Unilateral $408 $376 Mammography Direct Digital Bilateral $566 $520 X-Ray - Elbow 2 vws $241 $162 X-Ray - Finger(s) $182 $162 Breast Tomosynthesis Screening Add On $160 $160 Abdomen - Single View $289 $200 C Spine- 2 or 3 views $311 $266 Chest- PA & Lateral $298 $200 Chest- PA or AP $266 $162 Foot- Minimum 3 views $278 $200 Knee- 3 Views $290 $200 LS Spine- AP & Lateral $317 $266 X-Ray - Hip Uni 2-3 Views $290 $175 Shoulder- min 2 view $256 $200 Fluoroguidance for Spinal Injection $704 $336 DXA Scan Axial Skelton $503 $429
5 Laboratory The following charges include the hospital's 30 most common laboratory procedures. Reference Lab ABO Type $59 Amylase Serum $26 Basic Metabolic Panel $30 Blood Gas, Calc 02 Sat $79 CK (CPK) $27 CKMB (Mass Assay) $37 Complete Blood Count (CBC)- With differential, automated $32 Complete Blood Count (CBC)- Without differential $26 Comprehensive Metabolic Panel $43 Culture, Urine $33 Glycohemoglobin (HGB A1C) $40 Hepatic Panel $26 Lipid Profile $52 Magnesium, Serum $24 Partial Thromboplastin Time (PTT) $25 Phosphorus, Serum $19 POC Blood Sugar $10 Potassium Serum $19 Prostatic Specific Antigen $75 Prothrombin Time (PT) $16 Renal Function Panel $35 RH Factor $36 Surgical Pathology Level 4, Gross & Micro $163 T4-Free $37 Thyroid Stimulating Hormone $69 Troponin $40 Urinalysis $9 Urinalysis- With Microscopic $13 Venipuncture, Routine $9 Vitamin D 25 Hydroxy $121
6 BILLING INFORMATION BILLING POLICY Hospital Billing Policies The patient's guarantor is financially responsible for service provided to the patient at The Christ Hospital. If the patient is the beneficiary of government or private health care coverage, The Christ Hospital will bill the third party payer. The guarantor's share of the amount billed for services (co-payments and deductibles) and any amounts for services not covered by the third party payer are payable at the time of service. The Christ Hospital will bill the guarantor for any remaining balance that is the responsibility of the guarantor under terms of the payer contract and for charges for services that may not be covered by the third party payer consistent with the payer contract. Upon request, The Christ Hospital will provide the guarantor with an itemized bill. The Christ Hospital does not charge interest on unpaid balances owed by the patient's guarantor. The Christ Hospital encourages the patient to contact their insurance company to verify details of their respective coverage/financial obligation. If you are worried about paying your medical bills or if you have no health insurance, please talk to one of our financial counselors about payment plans or discounts. The Christ Hospital offers financial counseling to assist and aid in meeting financial obligations. Please call the Customer Service Department for more information. Physician Fees, Specialists, Additional Tests listed on the Price Disclosure document do not include charges for physician fees, specialists, or charges for any additional tests ordered for your care. FREQUENTLY ASKED QUESTIONS REGARDING "BILLING" Q. What is a guarantor? A. A guarantor is a person held responsible by the Christ Hospital for medical expenses incurred on a patient's behalf. This may be the patient, parent, legal guardian(s), or agent(s). Q. If I have questions regarding my bill, who can I call? A. Please contact our Customer Service Department at (844) (toll-free). Q. What is a deductible? A co-payment? Co-insurance? A. A deductible is the amount you pay each year before your plan begins paying benefits. This amount is usually a set dollar amount. A co-payment is a cost sharing agreement in which you pay a flat-dollar fee for a specific service. An example would be where the insurance plan charges a flat $50 co-payment for all emergency room visits. Co-insurance is the portion of your health care expenses for which you are responsible. If your coinsurance is 20%, then you would pay 20% of the expense after your deductible is met and your insurance company would pay the remaining 80%. You should check with your insurance company for specifics for your plan of coverage. Q. What is an Explanation of Benefits (EOB) or Explanation of Payment (EOP)? A. These are documents showing a detailed listing of how your insurance company processed your claim or bill. An EOB or EOP is mailed by your insurance company directly to you.
7 Q. Which methods of payment can I use to pay my bill? A. The Christ Hospital accepts payments made by cash, check, money order, or credit card. We accept Visa, MasterCard or American Express. MAILING ADDRESS FOR PAYMENTS: The Christ Hospital P.O. Box Cinti, OH CUSTOMER SERVICE TOLL FREE: :00 A.M. - 6:00 P.M. EST M-F Consumers can access a number of government and private Websites, which provide additional information on hospitals' charges and quality. For a complete listing of available online resources, please visit the Consumer's Guide to Quality Health Care in Ohio at
Effective July 1, 2016
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An independent licensee of the Blue Shield Association A17436 (01/2017) Benefit modifications for members with Full PPO 250 80/60 Effective January 1, 2017 The Full PPO 250 80/60 plan name will be changed
SUPRO: 2018 SCHEDULE OF BENEFITS - EMPLOYEE COST SHARING
SU Pro (In- and Out-of-) In - Out -of- Cost Sharing Definitions Annual Deductible 1 Coinsurance Annual Out-of-Pocket Maximum 2 $200 per individual with a maximum of $400 for a family 5% of allowable amount
Summary of Benefits: MyCare Rx 29 (HMO) Yellowstone County
Summary of Benefits: MyCare Rx 29 (HMO) Yellowstone County January 1, 2018 December 31, 2018 This is a summary of drug and health services covered by PacificSource Medicare MyCare Rx 29 (HMO). The benefit
Booklet Contents. Senior Blue (HMO) (H3384) Summary of Benefits. Forever Blue Medicare (PPO) (H5526) Summary of Benefits
MEDICARE ADVANTAGE 2017 Booklet Contents Senior Blue (HMO) (H3384) Summary of Benefits Forever Blue Medicare (PPO) (H5526) Summary of Benefits Optional Supplemental Dental Benefits Summary of Benefits
Blue Cross Select Silver 94 Blue Cross Preferred Silver 94
Blue Cross Select Silver 94 Blue Cross Preferred Silver 94 An individual HMO health plan from Blue Care Network of Michigan. Blue Cross Select You may choose from a select network of quality primary care
AvMed Network: $1,500 individual / $3,000 family Doesn t apply to preventive care. What is the overall deductible?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.avmed.org or by calling 1-800-376-6651. Important Questions
Summary of Benefits. for CareMore Breathe (HMO SNP), CareMore Heart (HMO SNP) and CareMore Diabetes (HMO SNP) Available in Stanislaus County
Summary of Benefits for, CareMore Heart (HMO and Available in Stanislaus County SBSTANBRTHRTDBT15 Y0017_15_081488A CHP CMS Accepted (09082014) Section I: Introduction to Summary of Benefits You have choices
Schedule of Benefits. Plan Information Participating Provider Non-Participating Provider. Deductible: $250 / $750 Rx: $10/$25/$40/$40 Coinsurance: 0%
Schedule of Benefits UPMC Business Advantage PPO - Premium Network Primary Care Provider: $20 Copayment per visit Specialist: $20 Copayment per visit Deductible: $250 / $750 Rx: $10/$25/$40/$40 Coinsurance:
In-Network: $1,000 Ind / $2,000 Family Non-Network: $2,000 Ind / $4,000 Family. What is the overall deductible?
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.chckansas.com or by calling 1-866-611-7337. Important
The Deductible is applicable to all covered services except for flat dollar Copayment services.
PRIORITY HEALTH www.priorityhealth.com/mpsers PRIORITYHMO SM PLUS PLAN MICHIGAN PUBLIC SCHOOL EMPLOYEES RETIREMENT SYSTEM (MPSERS) Effective January 1, 2017 through December 31, 2017 The HMO Plus plan
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at https://eoc.anthem.com/eocdps/fi or by calling (855) 333-5735.
Keystone 65 Choice Point-of-Service Rider An Addendum to Your Evidence of Coverage
Keystone 65 Choice Point-of-Service Rider An Addendum to Your Evidence of Coverage Effective January 1, 2008 through December 31, 2008 1-800-645-3965 TTY/TDD: 1-888-857-4816 Seven days a week 8 a.m. 8
Summary of Benefits: Essentials Rx 6 (HMO)
Summary of Benefits: Essentials Rx 6 (HMO) Essentials Rx 27 (HMO) Central Oregon, Eastern Oregon, and Mid-Columbia Gorge January 1, 2018 December 31, 2018 This is a summary of drug and health services
Annual Notice of Changes for 2016
True Blue Rx Option I (HMO-POS) offered by Blue Cross of Idaho Care Plus, Inc. Annual Notice of Changes for 2016 You are currently enrolled as a member of True Blue RX Option I (HMO-POS). Next year, there
Schedule of Benefits (GR-9N-S DE)
Schedule of Benefits (GR-9N-S-01-001-01 DE) Plan Sponsor: The Church of Jesus Christ of Latter-Day Saints-Senior Missionaries Group Policy Number: 840232 Issue Date: June 3, 2013 Effective Date: August
FULL PAYMENT IN PAYMENTS. Computed Tomography (CT)
Private Pay Fees For the convenience our patients, Diagnostic Outpatient Imaging particpates in most group healthcare plans (Medicare, Blue Cross/Blue Shield, Aetna, etc.) Under these programs we accept
Summary of Benefits. for Anthem Senior Advantage Basic (HMO)
Summary of Benefits for Anthem Senior Advantage Basic (HMO) Available in Ashland, Clermont, Cuyahoga, Darke, Fairfield, Franklin, Fulton, Geauga, Lake, Licking, Lorain, Madison, Medina, Ottawa, and Warren
SUMMARY OF BENEFITS Advantage MD Health Plans
2018 Advantage MD Health Plans SUMMARY OF BENEFITS JOHNS HOPKINS ADVANTAGE MD (PPO) JOHNS HOPKINS ADVANTAGE MD PLUS (PPO) JOHNS HOPKINS ADVANTAGE MD (HMO) Effective January 1, 2018 through December 31,
Anthem BlueCross BlueShield Christian Care Communities Blue Access PPO Coverage Period: 01/01/ /31/2015 Summary of Benefits and Coverage:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com or by calling 1-888-650-4047. Important Questions