POLICY TITLE: Centura Health Financial Assistance Policy

[Pages:17]POLICY TITLE: Centura Health Financial Assistance Policy

DEPARTMENT: Revenue Management

ORIGINATION DATE: 11/01/2006

CATEGORY: Billing

EFFECTIVE DATE: July 1, 2016

ADDENDUM C NON-COVERED PROVIDERS

(Revised 9/25/2018) *Provider list to be updated quarterly.

The following professional charges are not covered by the Centura FAP. Inquiries should be made by the patient with these organizations directly as they may have their own financial assistance policies.

Group Name 1ST CHOICE SURGICAL SERVICES 4319 CONSULTING LLC 5280 ANESTHESIA 5280 PEDIATRIC DENTISTRY AARON SMITH PLASTIC SURGERY ABODE HOSPICE AND HOME HEALTH ACADEMY PARK PEDIATRICS ACCORD SURGICAL ASSISTING, LLC ADVANCED ANESTHESIA ASSOCIATES ADVANCED BRAIN AND SPINE, LLC ADVANCED EAR, NOSE & THROAT, INC ADVANCED GYNECOLOGY & INFERTILITY, PC ADVANCED ORTHOPEDIC AND SPORTS MEDICINE SPECIALISTS, PC ADVANCED PEDIATRICS ADVANCED SPINE & SPORTS SPECIALISTS, LLC ADVANCED UROLOGICAL CARE ADVANCED UROLOGY, PC ADVANCED WOMEN'S HEALTH INSTITUTE ADVANTAGE ENT, LLP ADVENTURE DENTAL, VISION, & ORTHODONTICS AFFILIATES IN ORAL & MAXILLOFACIAL SURGERY ALAN REISMAN, DDS ALBRECHT WOMEN'S CARE DENVER IVF ALL ABOUT WOMENS CARE ALL STAR RECRUITING ALLERGY & ASTHMA CENTER ALLERGY & ASTHMA SPECIALISTS ALLERGY ASTHMA AND SINUS CENTER LLC ALLPRIA HEALTHCARE ALPINE EYE CLINIC ALPINE SURGICAL LLC

All official Centura Health policies are maintained electronically and are subject to change. No printed policy should be taken as the official policy except to the extent it is consistent with the current policy that is electronically maintained.

Category ? Statewide Financial Assistance Policy

Page 1 of 17

ALPINE UROLOGY PC ALTA VISTA DERMATOLOGY ALTITUDE ORAL MAXILLOFACIAL DENTAL IMPLANT CENTER AMERICAN SURGICAL PROFESSIONALS AMERICAN VEIN AND VASCULAR INSTITUTE ANESTHESIA CONSULTANTS OF WESTERN COLORADO, PLLC ANESTHESIA CONSULTANTS PC ANIMAS FOOT AND ANKLE PC ANIMAS PLASTIC SURGERY, PC ANIMAS SPINE ARAPAHOE PARK PEDIATRICS ARAPAHOE PROFESSIONAL SURGICAL ASSISTANTS ARBOR FAMILY MEDICINE ASARCH CENTER FOR DERMATOLOGY, LASER & MOHS SURGERY ASCENT MEDICAL, LLC ASPEN SURGICAL ARTS ASSOCIATES IN EYE CARE, PC ASSOCIATES IN GASTROENTEROLOGY, PC ASSOCIATES IN MAXILLOFACIAL & ORAL SURGERY, PC ASSOCIATES IN WOMEN'S CARE, PC ASSOCIATES OF OTOLARYNGOLOGY ASSURE NEUROMONITORING, LLC AURORA PLASTIC SURGERY, PC AUTOBEE DENTAL CENTER AUXILLIUM MEDICAL SERVICES, LLC AVISTA ADVENTIST HOSPITAL AVISTA WOMEN'S CARE AXIS HEALTH SYSTEMS BANNER HEALTH CLINIC - ANESTHESIA BANNER HEALTH CLINIC - MEDICAL ONCOLOGY/HEMATOLOGY BARIATRIC AND AESTHETIC SURGERY ASSOCIATES BARITRIC SPA BELLA NATURAL WOMEN'S CARE BETH ROLAND, MD, PC BISHOP/PETERSON, MD, PC BLUE SKY NEUROLOGY A DIVISION OF CAREPOINT PC BOULDER BONE AND JOINT BOULDER EYE SURGEONS BOULDER MEDICAL CENTER BOULDER NEUROSURGICAL & SPINE ASSOC, PLLC BOULDER NEUROSURGICAL & SPINE ASSOCIATES BOULDER PAIN INSTITUTE, PC BOULDER PLASTIC SURGERY PROF LLC BOULDER VALLEY EAR, NOSE & THROAT ASSOCIATES BOULDER VALLEY NEUROLOGY

All official Centura Health policies are maintained electronically and are subject to change. No printed policy should be taken as the official policy except to the extent it is consistent with the current policy that is electronically maintained.

Category ? Statewide Financial Assistance Policy

Page 2 of 17

BOULDERCENTRE FOR ORTHOPEDICS BRAY SURGICAL ASSISTING BRIAN WILLOUGHBY, MD, PC BRIARGATE PEDIATRIC DENTISTRY PC BRIGHT NOW DENTAL BRIGHTON CARDIOLOGY BRITT A BUCKLEY, MD, PC BROADWAY PLASTIC SURGERY BROOMFIELD FAMILY PRACTICE BROOMFIELD PEDIATRICS BURN AND RECONSTRUCTIVE CENTERS OF COLORADO BURNHAM ORAL SURGERY BUTTON FAMILY PRACTICE CANON FAMILY MEDICINE CARE PLUS SYSTEMS, INC CAREPOINT NEUROSURGERY, PLLC CAREPOINT, PC CAROL A GOLDBERG, MD CASTLE ROCK FOOT AND ANKLE CARE CASTLE ROCK KIDS DENTISTRY CASTLE ROCK ORAL & MAXILLOFACIAL SURGERY CASTLE ROCK PEDIATRICS CASTLE ROCK SMILES PEDIATRIC DENTISTRY CENTENNIAL FOOT CARE CENTENNIAL PEDIATRICS PC CENTENNIAL VALLEY PEDIATRICS CENTER FOR COSMETIC SURGERY CENTER FOR CRANIOFACIAL & FACIAL PLASTIC SURGERY CENTER FOR HEADACHES & TMJ & SLEEP DISORDERS CENTER FOR PLASTIC & AESTHETIC SURGERY CENTER FOR PLASTIC SURGERY AT CASTLE ROCK INC CENTER FOR SPINE & ORTHOPEDICS, PC CENTER FOR WOMEN'S HEALTH CENTER OF SURGICAL SPECIALISTS, PC CENTURA HEALTH AT HOME CENTURA HEALTH PHYSICIAN GROUP HOSPITALISTS ST MARY CORWIN CHARLES H RIPP MD PC CHERRY CREEK EYE PHYSICIANS & SURGEONS, PC CHERRY CREEK ORAL AND MAXILLOFACIAL SURGERY, PC CHEYENNE FOOT & ANKLE, INC CHILDREN'S CLINIC CHILDREN'S EYE CENTER, PC CHILDREN'S EYE PHYSICIANS CHILDREN'S HOSPITAL COLORADO CHILDREN'S HOSPITAL COLORADO - ANESTHESIA DEPARTMENT

All official Centura Health policies are maintained electronically and are subject to change. No printed policy should be taken as the official policy except to the extent it is consistent with the current policy that is electronically maintained.

Category ? Statewide Financial Assistance Policy

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CHILDREN'S HOSPITAL COLORADO - EMERGENCY DEPARTMENT CHILDREN'S HOSPITAL COLORADO - NEONATOLOGY CHILDREN'S HOSPITAL COLORADO - PEDIATRIC CARDIOLOGY CHILDREN'S HOSPITAL COLORADO - PEDIATRIC HOSPITAL MEDICINE CHILDREN'S HOSPITAL COLORADO - PEDIATRIC OTOLARYNGOLOGY CHILDREN'S HOSPITAL OF COLORADO - HOSPITALIST CHIPS CHILDREN'S INPATIENT PHYSICIAN SERVICES CHPG BEHAVIORAL HEALTH PENROSE PAVILION CHPG SPC METRO A CHRISTOPHER G VIALPANDO MD, PLLC CK SURGICAL, LLC CLARITY DERMATOLOGY, PLLC CLEAR CREEK MEDICAL GROUP CLINICA FAMILY HEALTH SERVICES CLINTON CALLAHAN, DMD, PC CNS MEDICAL GROUP, PC COAL CREEK FAMILY MEDICINE COAL CREEK ORAL SURGERY AND DENTAL IMPLANT CENTER, PLLC COAL CREEK PLASTIC & COSMETIC SURGERY COLORADO ALLERGY & ASTHMA CENTERS PC COLORADO BARIATRIC SURGERY INSTITUTE COLORADO BLOOD AND CANCER CARE COLORADO BRAIN & SPINE INSTITUTE, LLC COLORADO CARDIOVASCULAR SURGICAL ASSOC PC COLORADO CENTER FOR GYNECOLOGIC ONCOLOGY COLORADO CENTER FOR REPRODUCTIVE MEDICINE COLORADO CENTER OF ORTHOPAEDIC EXCELLENCE COLORADO CHILDREN'S COLORADO - ORTHO COLORADO CHILDRENS MEDICAL GROUP COLORADO CLINICS FOR THE FOOT AND ANKLE COLORADO COLON & RECTAL SPECIALISTS COLORADO DERMATOLOGY CENTER COLORADO DERMATOLOGY INSTITUTE COLORADO EAR, NOSE, & THROAT COLORADO ENDOCRINOLOGY COLORADO ENT AND ALLERGY COLORADO EYE INSTITUTE COLORADO FACIAL PLASTIC SURGERY CENTER COLORADO FAMILY ORTHOPEDICS COLORADO FOOT AND ANKLE COLORADO FOOT AND ANKLE CLINIC, PC COLORADO FOOT AND ANKLE SPORTS MEDICINE, LLC COLORADO HAND CENTER COLORADO HEARING & BALANCE CLINIC COLORADO HEART AND VASCULAR PC

All official Centura Health policies are maintained electronically and are subject to change. No printed policy should be taken as the official policy except to the extent it is consistent with the current policy that is electronically maintained.

Category ? Statewide Financial Assistance Policy

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COLORADO HEART CLINIC COLORADO HOSPITALIST COMPANY COLORADO IMAGING ASSOCIATES, PC COLORADO INFECTIOUS DISEASE ASSOCIATES COLORADO INSTITUTE OF COLON & RECTAL SURGERY COLORADO KIDNEY CARE PC COLORADO NEURODIAGNOSTICS COLORADO OPHTHALMOLOGY ASSOCIATES COLORADO OPTHAMOLOGY ASSOCIATES COLORADO ORAL SURGERY COLORADO ORTHOPAEDICS COLORADO ORTHOPEDIC CONSULTANTS, PC COLORADO PAIN CARE COLORADO PAIN CONSULTANTS COLORADO PHYSICIANS SURGICAL ASSISTANTS, INC COLORADO PLASTIC SURGERY CENTER COLORADO PODIATRY CONSULTANTS PC COLORADO PRIMARY HEALTH CARE COLORADO PULMONARY ASSOCIATES COLORADO PULMONARY INTENSIVISTS COLORADO REHABILITATION AND OCCUPATIONAL MEDICINE COLORADO REHABILITATION PHYSICIANS COLORADO RETINA ASSOCIATES, PC COLORADO SPRINGS DERMATOLOGY CLINIC, PC COLORADO SPRINGS EAR ASSOCIATES COLORADO SPRINGS EYE CLINIC COLORADO SPRINGS FOOT & ANKLE CLINIC COLORADO SPRINGS INTERVENTIONAL PAIN MANAGMENT PC COLORADO SPRINGS NEPHROLOGY COLORADO SPRINGS NEUROLOGICAL ASSOCIATES COLORADO SPRINGS ORAL SURGERY COLORADO SPRINGS ORTHOPAEDIC GROUP COLORADO SPRINGS ORTHOPAEDIC GROUP - AUDUBON COLORADO SPRINGS ORTHOPAEDIC GROUP - HAND & UPPER EXTREMITY COLORADO SPRINGS ORTHOPAEDIC GROUP - SFMC COLORADO SPRINGS ORTHOPAEDIC GROUP - SPINE CENTER COLORADO SPRINGS PEDIATRIC DENTISTRY COLORADO SPRINGS PULMONARY CONSULTANTS, PC COLORADO SPRINGS RADIOLOGISTS, PC COLORADO SPRINGS SURGICAL ASSOCIATES, PC COLORADO SPRINGS UROLOGICAL ASSOCIATES, PLLC COLORADO SURGICAL AND CRITICAL CARE ASSOCIATES COLORADO SURGICAL SERVICE PC COLORADO TRAUMA SERVICE PC COLORADO VOICE CLINIC, PC

All official Centura Health policies are maintained electronically and are subject to change. No printed policy should be taken as the official policy except to the extent it is consistent with the current policy that is electronically maintained.

Category ? Statewide Financial Assistance Policy

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COMFORT DENTAL ORAL SURGERY COMMUNITY FOOT & ANKLE CLINIC COMPHEALTH LOCUMS TENENS COMPREHENSIVE ENT, PC CONCEPTIONS REPRODUCTIVE ASSOCIATES OF COLORADO CONRAD J TIRRE, MD CONSULTANTS IN NEPHROLOGY AND HYPERTENSION COOL MOUNTAIN KIDS PEDIATRIC DENTISTRY CORNEAL CONSULTANTS OF COLORADO, PC CORNERSTONE ORTHOPEDICS & SPORTS MEDICINE CORNERSTONE PEDIATRIC ASSOCIATES, INC CORWIN CLINIC SURGICAL, PC CRITICAL CARE AND PULMONARY CONSULTANTS, PC CRITICAL CARE, PULMONARY & SLEEP ASSOC PLLP CRNA ASSOCIATES, INC CROWLEY COUNTY CORRECTIONAL FACILITY CU UROLOGY SOUTH DENVER CUTARELLI VISION CUTTING EDGE SURGICAL, INC DAVITA MEDICAL GROUP-BRIARGATE OFFICE DAVITA MEDICAL GROUP-BRIARGATE OFFICE OB DAVITA MEDICAL GROUP-BRIARGATE OFFICE PEDIATRICS DAVITA MEDICAL GROUP-EAST OFFICE OB EAST DAVITA MEDICAL GROUP-EAST OFFICE PEDIATRICS DAVITA MEDICAL GROUP-HOSPITALISTS OFFICE DAVITA MEDICAL GROUP-MCP DAVITA MEDICAL GROUP-MCP NEUROLOGY DAVITA MEDICAL GROUP-MCP ORTHOPEDICS AND PODIATRY DAVITA MEDICAL GROUP-SOUTHWEST OFFICE DEBORA MA, MD PC DELTA LOCUM TENENS DENTAL ARTS OF CHERRY HILLS DENVER BACK PAIN SPECIALISTS, LLC DENVER EAR ASSOCIATES DENVER HEALTH MEDICAL CENTER DENVER HEART DENVER INTERNAL SPINE CENTER DENVER METRO ORTHOPAEDICS PC DENVER NEURODIAGNOSTICS, LLC DENVER NEUROLOGICAL CLINIC DENVER ONCOLOGY, PC DENVER SPINE CENTER DEPENDABLE SURGICAL ASSISTANTS, INC DERMATOLOGY ASSOCIATES OF COLORADO DIEHL ANESTHESIA

All official Centura Health policies are maintained electronically and are subject to change. No printed policy should be taken as the official policy except to the extent it is consistent with the current policy that is electronically maintained.

Category ? Statewide Financial Assistance Policy

Page 6 of 17

DIGESTIVE DISEASE SPECIALISTS OF COLORADO DIGESTIVE HEALTH ASSOCIATES, PC DIVERSIFIED RADIOLOGY OF COLORADO, PC DOCTORS MEDICAL GROUP OF COLORADO SPRINGS DR KIM K DERNOVSEK DRS. DAY & RUBY DRS. MANN & PULS DRS. RENDLER & ARGUELLO DRY CREEK SURGERY PC DTC EYE ASSOCIATES, PC DURANGO DERMATOLOGY DURANGO NEUROLOGICAL ASSOCIATES, PC EAGLE-SUMMIT FOOT & ANKLE, PC EAR, NOSE AND THROAT OF PARKER EBERT FAMILY CLINIC EDWARD K RACZKA, DPM, PC EITAN MEDINA, MD, PC ELDORADO RETINA ASSOCIATES PC ELEVATED ORAL AND MAXILLOFACIAL SURGERY ELITE NEUROMONITORING, LLC ELITE OCULOPLASTIC SURGERY, PC ENDOCRINE SERVICES, PC EPIC ANESTHESIA ERICKSON PEDIATRIC DENTISTRY & ORTHODONTICS ERIK H RIEGER, MD, PC ESPRIT WOMAN CARE EVANS ARMY COMMUNITY HOSPITAL (FORT CARSON) EXCELLENCE IN ORAL & MAXILLOFACIAL SURGERY EXCEPTIONAL CARE FOR WOMEN, PLLC EXEMPLA GOOD SAMARITAN HOSPITAL EXEMPLA ST JOSEPH HOSPITAL EYE ASSOCIATES OF COLORADO SPRINGS, PC EYE CARE CENTER OF NORTHERN COLORADO FAMILY HEALTH CARE CENTER FLATIRON INTERNAL MEDICINE FLATIRONS OPHTHALMOLOGY FLATIRONS SURGICAL ASSISTING, INC. FLORENCE MEDICAL CENTER FOCUS ON KIDS FOOT AND ANKLE INSTITUTE OF COLORADO FOOT SPECIALIST ASSOCIATES, PC FOOTHILLS ANESTHESIA, LLC FOOTHILLS UROLOGY FOUR CORNERS FOOT AND ANKLE PC FOUR CORNERS OB/GYN

All official Centura Health policies are maintained electronically and are subject to change. No printed policy should be taken as the official policy except to the extent it is consistent with the current policy that is electronically maintained.

Category ? Statewide Financial Assistance Policy

Page 7 of 17

FOUR CORNERS ORAL & MAXILLOFACIAL SURGERY FOUR CORNERS SMILES 4 KIDS, INC. FREELANCE ASSISTANTS FREMONT FOOT AND ANKLE FRONT RANGE CENTER FOR SPINE & SPORTS MEDICINE FRONT RANGE EYE PHYSICIANS FRONT RANGE ORTHOPEDICS & SPINE FRONT RANGE OTOLARYNGOLOGY & FACIAL PLASTIC SURGERY PC FRONT RANGE SPINE AND NEUROSURGERY FRONT RANGE SPINE AND NEUROSURGERY, PC FRONT RANGE SURGICAL ASSOCIATES, PC FRONT RANGE SURGICAL SERVICES, PC FRONTIER NEUROLOGY AND NEUROMUSCULAR CLINIC GARDEN SURGICAL ASSOCIATES GARY R. SNIDER, MD GENITOURINARY SURGICAL CONSULTANTS GOLDSTAR SURGICAL ASSISTING GORMAN MEDICAL LLC GREENWOOD EAR, NOSE & THROAT SPECIALISTS, PC GREENWOOD PEDIATRICS, PC GREGORY J LIEBSCHER, MD GROSSMAN PLASTIC SURGERY GUARDIAN ANESTHESIA SERVICES INC GUARDIAN ANGELS HEALTH CENTER HAAS VISION CENTER HAND SURGERY ASSOCIATES, PC HANSON CLINIC PC HARMONY WOMEN'S CENTER HEALOGICS HEALTHSOUTH REHABILITATION HOSPITAL HEARTLAND CANCER-ONCOLOGY HEIDI J OSTER MD, PC HEOLOGICS HERITAGE INTERNAL MEDICINE, PC HIGH COUNTRY SURGICAL ASSISTING, INC. HIGH PLAINS ANESTHESIA CONSULTANTS, PC HIGH PLAINS COMMUNITY HEALTH CENTER HIGH PLAINS UROLOGY HIGHLANDS RANCH ORAL & FACIAL SURGERY HINES-SIGHT HOPE INTERNAL MEDICINE OF PUEBLO, LLC HORIZONS FOOT & ANKLE CLINIC IMMUNOE HEALTH CENTERS IMPLANT AND ORAL SURGERY CENTER INCLINE ORTHOPAEDICS

All official Centura Health policies are maintained electronically and are subject to change. No printed policy should be taken as the official policy except to the extent it is consistent with the current policy that is electronically maintained.

Category ? Statewide Financial Assistance Policy

Page 8 of 17

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