At Carle, we are committed to helping you make informed choices about your care. That includes helping you know, in advance, an estimate of the amount you owe after your insurance pays, or if you do not have or provide insurance, how much you will be charged for services and goods.
Carle provides estimates for a wide range of common medical services by determining an average service bundle from the historical billing of the service. This estimate is a good-faith attempt to let you know your portion of the cost for the service selected. The resulting estimate may not match your final bill exactly. Your final bill will depend on actual services, drugs, supplies and procedures performed as determined by your doctors.
Please keep in mind that there may be separate charges from the hospital services, such as Carle Medical Supply, Arrow Ambulance, Home Infusion
and other services depending on the individual situation that will not be included in this estimate.
When
you have the opportunity to shop for medical services, it is best to contact
your insurance carrier to understand which services and goods will be covered
and which will be your responsibility. They are most knowledgeable about the specific benefit plan, coverages and out of pocket responsibilities that your plan provides.
Hospital charges are the amount a hospital bills for a
service. Because of varying reimbursements from insurers, patients most often
pay far less than the amount listed.
Our Patient Financial Services representatives are available to help you understand charges and provide estimates Monday through Friday, 8 a.m. to 5 p.m. at (888) 71-CARLE or (888) 712-2753.
If you believe the estimated amount due may create a financial hardship, you may be eligible for the Carle Financial Assistance Program that may offset some or all of your costs. To learn more about this program, click here.
Please gather the following information before completing this form:
Providing your insurance information will enable us to provide an estimate of the amount you will owe after your insurance pays. If you choose not to provide this information, we will provide you with the estimated total gross charges using an average service bundle from the historical billing of the service, and you will need to apply your plan's out of pocket amounts (e.g. deductible, co-insurance, non-covered, etc.) to calculate your estimated out of pocket costs. Because these calculations by insurers are typically based on the amount the insurer pays, and is NOT based on the hospital's billed gross charges, we recommend you contact your insurer for an estimate if you do not want to provide your insurance information to Carle.
The amount shown in an estimate is based on the information you provide. This estimate cannot and should not be relied on as the actual charges and/or payments you will be responsible for paying, and is in no way a quote, guarantee or contract for the amount that you may owe. You will be responsible for the actual amount you owe for services rendered.
Tips for Completing the Price Estimate Form
Patient First and Last Name
Please enter the name of the patient as it appears on the insurance card.
Phone Number
The best phone number to reach you.
Birthdate
Patient birthdate is needed to access insurance benefits.
Referring Physician Name
The physician who ordered your test or procedure. Enter the First and
Last Name of your physician. For Surgical procedures please enter the
Surgeon's first and last name.
Referring Physician Phone Number
Physician office number
Procedure Code provided by Physician
Five digit CPT code assigned to the procedure or test. Enter code if
available.
Preferred Facility Type
Facility type where procedure will be performed.
Description of Procedure/Service
Ask your provider to clearly print the name of the procedure(s). Correct
spelling is important as many surgery names sound familiar. If you have
more than one procedure please separate them by a comma.
Anticipated date of service
If anticipated date is unknown enter approximate date (mm/yyyy).
Health Insurance Company
Please enter the insurance company name as it appears on the patient’s
insurance card (for example Aetna PPO).
Policy Holder’s Name
The policy holder's name as it appears on the patient’s insurance card.
Member ID/Policy #
Please enter the Member ID/Policy # or subscriber # as it appears on the
patient’s insurance card. This can be a combination of numbers and/or letters.
Group #
Please enter the Group Number or Plan Name/Description as it appears on the
patient’s insurance card. This can be a combination of numbers and/or letters.
Health Insurance Company Phone
Please enter the customer service or provider phone number that appears on your
insurance card.
Co-insurance
Your share
of the costs of a covered health care service, calculated as a percent (for
example, 20%) of the allowed amount for the service. You pay co-insurance plus
any deductibles you owe. For example, if the health insurance or plan’s allowed
amount for an office visit is $100 and you’ve met your deductible, your
co-insurance payment of 20% would be $20. The health insurance or plan pays the
rest of the allowed amount.
Co-payment
A fixed
amount (for example, $15) you pay for a covered health care service, usually
when you receive the service. The amount can vary by the type of covered health
care service.
Deductible
The amount
you owe for health care services your health insurance or plan covers before
your health insurance or plan begins to pay. For example, if your deductible is
$1000, your plan will not pay anything until you’ve met your $1000 deductible for
covered health care services subject to the deductible. The deductible may not
apply to all services.
Network
The
facilities, providers and suppliers your health insurer or plan has contracted
with to provide health care services.
Non-Preferred Provider
A provider who
does not have a contract with your health insurer or plan to provide services to
you. You will pay more to see a non-preferred provider. Check your policy to see
if you can go to all providers who have contracted with your health insurance
or plan, or if your health insurance or plan has a “tiered” network and you
must pay extra to see some providers.
Out-of-Pocket Limit
The most you
pay during a policy period (usually a year) before your health insurance or
plan begins to pay 100% of the allowed amount. This limit never includes your
premium, balance-billed charges or health care your health insurance or plan
doesn’t cover. Some health insurance or plans do not count all of your
co-payments, deductibles, co-insurance payments, out-of-network payments or
other expenses toward this limit.
Premium
The amount that must be paid for your health insurance or
plan. You and/or your employer usually pay it monthly, quarterly or yearly.
Beginning January 1, 2021, the U.S. Department of Health & Human Services and the Centers for Medicare & Medicaid Services requires hospitals and health systems to post their "current, standard charges." You can download and view these files here: