Procedure Billing and Insurance

What to expect when you are billed for a colonoscopy, upper endoscopy (EGD), ERCP, or other procedure with our gastroenterologists, and how to check your coverage before your visit.

Download the billing sheet (PDF) Billing questions: 858-888-7730

Also available in Español, Tiếng Việt, and 中文.

You may receive up to four separate bills

Insurance and prior authorization

• Prior authorization: our office contacts your insurance company to obtain prior authorization for your procedure.
• Know your policy: it is your responsibility to understand your benefits. Call the member services number on your insurance card to confirm coverage and your out-of-pocket costs (deductible, copay, and coinsurance).
• HMO and IPA plans need an approved referral or authorization before your procedure can be scheduled. See accepted insurance.
• Surveillance colonoscopy (commercial insurance): if you have a history of colon polyps and your colonoscopy is done less than 10 years after your last one, your insurance may not consider it "screening" or "preventive." Your deductible and copay may apply.

Check your coverage with these codes

Your insurance company can tell you what you will owe if you give them the procedure (CPT) and diagnosis (ICD-10) codes. These are the codes most often used for our procedures. Your final codes depend on what is done during the procedure, such as biopsies or polyp removal.

Other codes may apply. Ask our office if you need the codes for your specific procedure.

Screening vs. diagnostic colonoscopy

Under the Affordable Care Act, most private plans cover a screening colonoscopy for average-risk adults 45 and older with no cost to you, including removal of polyps found during the screening. A colonoscopy done because of symptoms, such as bleeding or a change in bowel habits, is diagnostic and may involve a deductible, copay, or coinsurance. Medicare covers screening colonoscopy; if a polyp is removed, a small coinsurance may apply, which is being phased out by 2030.

Surveillance after polyps: with commercial insurance, a surveillance colonoscopy done less than 10 years after your last one because of a history of colon polyps may not be considered "screening" or "preventive," so your deductible and copay may apply. Coverage varies by plan, so call your insurance with the codes above before your procedure.

Understanding your Explanation of Benefits (EOB)

• Total charges: the amount first billed to your insurance company. It is discounted to the contracted fee the provider accepts under its agreement with your plan.
• Allowed amount: the total the provider expects to receive from your insurance and you combined (also called the negotiated or expected amount).
• Payable amount: what your primary insurance will pay.
• Patient responsibility: the difference between the allowed and payable amounts, including deductibles, copays, coinsurance, and uncovered amounts. Secondary insurance may pay all or part of this, depending on your plan.

Cancellation fee

Please note: fees may apply if you cancel within 5 business days of your scheduled procedure.

Questions?

For the physician bill, call our billing department at 858-888-7730. For other billing or fee questions, call our office at 626-898-4560 or email templecity@uniohp.com. See also our procedure instructions.