Centers for Gastroenterology (CFGI) recommends that you call your insurance plan(s) prior to each new provider visit or service you receive to determine your specific benefits and coverage. Talking with your insurance plan(s) in advance does not guarantee coverage or payment for services, but will help you understand and prepare for any possible out-of-pocket health care expenses.The following questions will help guide you through this process. If your insurance plan(s) inform you that you need additional information from CFG before they can completely answer your questions, please call our Financial Services at 970-207-9773, and we will be happy to assist you.

For Any Service

Whenever you speak with an insurance representative, it is recommended any time you speak with an insurance company to obtain a reference number, name of the person you spoke with, date and time for your files. You will be able to reference this information in the future should you need additional benefit information or need to appeal/dispute claims.

  • Is this provider in network? Is the facility in network?
  • What network level or tier is this provider a part of?
  • What are the benefits for my upcoming service that are associated with this network level?
  • Do I need a prior authorization for this service and/or facility?
  • Do I need a referral for this service and/or facility?
  • What benefits do I have for facility charges, if they apply?
  • Do I have coverage to see a nurse practitioner or a physician assistant, or am I required to see a physician?

For Screening Colonoscopy

The following questions should be asked in addition to those above if you will be having a colonoscopy.

  • Do I have screening or preventive care benefits?
  • Is there a benefit cap on my screening or preventive care benefits? If so, what is it?
  • Will my colonoscopy be covered under my screening or preventive benefits?
  • My colonoscopy will be performed at an ambulatory surgery center (ASC). Are associated facility charges covered under my screening or preventive benefits? If not, what out-of-pocket expenses might I incur?
  • What benefits do I have for pathology and lab charges? Are these covered under my screening or preventive benefits?
  • What benefits do I have if my colonoscopy is not considered screening?

IMPORTANT information regarding Colonoscopy billing

We receive frequent calls from patients wondering how their insurance will pay for their Colonoscopy. We strive to be sure we are always providing you with accurate information, but we recommend you contact your insurance company for benefits.  Below is a brief explanation on Colonoscopy categories, and how insurance will likely process yours.

Diagnostic/Therapeutic Colonoscopy (Insurance will likely apply this to copays, deductibles, and coinsurance.)

Patient has a past and/or present gastrointestinal symptoms, polyps, or gastrointestinal disease.  This can include, but is not limited to, Rectal Bleed, Abdominal Pain, Constipation, ECT.

Preventive Colonoscopy “Screening” (Insurance will typically pay this at 100%).

Patient is asymptomatic (no gastrointestinal symptoms).  Patient must be over 50 years of age, have no personal or family history of gastrointestinal disease, colon polyps, and/or cancer.  The patient has not undergone a Colonoscopy screening purposes in the last 10 years.

Surveillance Colonoscopy (Insurance will likely apply this to copays, deductibles, and coinsurance.)

Patient is asymptomatic (no gastrointestinal symptoms).  Patient has a personal history of gastrointestinal disease, colon polyps, and/or cancer.  Patients in this category are required to undergo a colonoscopy at varying ages and intervals based on the patient’s history, meaning they are not eligible for a traditional “Screening Colonoscopy.”

High Risk Colonoscopy (Insurance may apply this to copays, deductibles, and coinsurance.)

Patient is asymptomatic (no gastrointestinal symptoms) and has a family history of gastrointestinal disease, colon polyps, and/or cancer.

 

Frequently Asked Questions

Can the physician change, add, or delete my diagnosis so that I can be considered a Screening Colonoscopy?

  1. The patient information is documented as a medical record from information you have provided as well as an evaluation and assessment from the physician. Strict government and insurance company documentation and coding guidelines prevent a physician from altering a patient’s chart or bill for the sole purpose of coverage determination. This is considered insurance fraud and is punishable by law.

My insurance company told me that CFG can change, add, or delete a CPT or Diagnosis Codes. Is that possible?

  1. This is a common occurrence and is usually due to miscommunication. Often, members call their insurance and advise them that they were scheduled for a Screening Colonoscopy at which time the member services representative advise them that it should be covered at 100%. However, the patient had a Colonoscopy 5 years prior for personal history of polyps and was placed on a 5-year recall, at which time it would be considered Surveillance Colonoscopy (See above definitions). Note: Screening Colonoscopies can only be coded as screening when the patient does not have a personal/family history, or symptoms.

 

Scenario 1: Patient’s father has a history of Colon Cancer. This will be billed as a High Risk Colonoscopy.

Scenario 2:  Patient had a Colonoscopy 5 years ago for personal history of colon polyps.  Provider recommended the patient return in 5 years for surveillance. This will be billed as a Surveillance Colonoscopy.

Scenario 3:  Patient is having constipation and abdominal pain. This will be billed as a Diagnostic Colonoscopy.

Scenario 4:  Patient is 60 years of age with no history of personal/family history of colon cancer or polyps and patients last Colonoscopy was 11 years ago. This will be billed as a Screening Colonoscopy.