CO 40 Denial Code: Why Insurance deny Emergency Room claims?

0
2236
CO 40: What is emergent/urgent care? And why insurance denied claim?

What is the Difference between Urgent Care and Emergency Room?

Urgent care can treat minor fractures, nonemergency x-rays, back pain, and cold and flu symptoms. At the same time, the emergency room may treat more severe conditions, such as chest pain, heart attack symptoms, and difficulty breathing.

Whether you go to urgent care or the emergency room depends on the medical situation you are in. If you are in an emergency, you should always go to the emergency room because urgent care cannot provide the level of care you may need. If you are not experiencing an urgent medical situation and the hours are between 8 AM and 5 PM (unless the center is open later or earlier), you may want to consider visiting an urgent care center.

When and Why Insurance Deny Emergency Room Claims?

When patients use non-ER facilities, it’s less costly for the Insurance, and that translates into lower overall healthcare cost—and lower insurance premiums—for everyone. But in the case of a life- or limb-threatening condition, an emergency room will likely be the only place that’s properly equipped to handle certain conditions.

Do Urgent care centers accept insurance?

It is up to the insurance provider whether they cover urgent care centers or not. However, many insurance providers cover urgent care visits, but patients will be expected to pay the co-pay or deductible implied by their plan.

You should also be aware that an urgent care center may choose not to accept your insurance, even if your insurance provider would otherwise pay for the care. This could be avoided by calling the urgent care center ahead of time and asking if they accept your insurance.

Look Up for “Self-pay” Rates

Websites such as Healthcare Bluebook, FairHealth and SolvHealth allow you to get an estimate of how much your urgent care visit is going to cost. The self-pay rate is the charge set by clinics for patients without insurance. It may also be possible to get a payment plan.

Call Before You Go

Calling ahead of time allows you to check for available time slots and leads to a better understanding of how the urgent care center charges patients without insurance. While calling beforehand, you may want to ask about their pricing for patients paying out of pocket.

Ask the Right Questions

When going for your visit, make a list of questions regarding pricing and services for the visit. Here are some examples:

  • How much will this test cost?
  • If I need an x-ray or additional testing, how much will it cost?
  • Is this the only test I need for today?
  • How much will this prescription medicine cost?
  • Is there an office visit fee?
  • What other administrative fees can I expect?
  • Are there separate charges for the office visit and in-house lab tests?
  • Is there a bundle price for certain services?

Health Insurance Claim Denial Reasons

An Insurance might deny your claim for several reasons:

  • A provider or facility isn’t in the health plan’s network.
  • A provider or facility didn’t submit the right information to the Insurance.
  • A health plan needed more information to pay for the services.
  • A health plan didn’t deem a procedure medically necessary.
  • A clerical error.

How to appeal health insurance claim denial?

Here are seven steps for winning a health insurance claim appeal:

  1. Find out why the health insurance claim was denied.
  2. Read your health insurance policy.
  3. Learn the deadlines for appealing your health insurance claim denial.
  4. Make your case.
  5. Write a concise appeal letter.
  6. Follow up if you don’t hear back.

Urgent Care Cost without Insurance (Self-Pay) in 2021

it is difficult to know how much an urgent care visit costs without insurance because every facility and company will charge differently depending on the services you’re receiving.

The Average Costs for Different Services at Urgent Care

Reason for Visit Price without insurance
Allergies $97
Acute Bronchitis $127
Earaches $110
Sore Throat $94
Pink Eye $102
Sinusitis $112
Urinary Tract Infections $111
Upper Respiratory Infections $111

 Office Visit Cost

Urgent Care Baseline Visit Fee What the office visit cost includes
American Family Care $140 Physician visit
Fast Med $119 or $199 Provider visit and 2 tests; provider visit and medical procedures
CityMD $200 Provider visit and minor procedures
NextCare $160 or $275 Office visit; additional in-clinic services
Patient First $129 Routine visit

Average Out of Pocket Urgent Care Costs in Major Cities*

City Out of Pocket Cost
New York City, NY $189
Los Angeles, CA $175
Chicago, IL $166
Philadelphia, PA $178
Houston, TX $180
Salt Lake City, UT $175
Seattle, WA $198
Wisconsin, ML $165
Las Vegas, NV $135

*These costs reflect the office visit cost, 1 test (ex: rapid flu, strep tests). Additional testing could range between $15-60 per test.  An x-ray could cost an additional $65, and higher-level services could add $99 or more.

 

Learn More…

Denial Reason CO-50: Non-Covered Services Medical Necessity

Coping up with Cybersecurity Risks in Healthcare Industry

Also learn about our Medical Billing Consultation Services for Emergency Rooms