Specialist Visit
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Specialist Visit Receipt Example
This receipt documents a cardiology follow-up at Chicago Heart & Vascular Institute, a CPT 99214 Level 4 established patient visit for hypertension management. The provider billed $285.00; after a $101.75 contractual adjustment, the allowed amount is $183.25. United Healthcare paid $123.25, leaving a $60.00 specialist copay. Referral Auth #REF-2025-7391 confirms the visit was pre-authorized.
This specialist visit receipt documents a follow-up dermatology visit (CPT 99213) with biopsy procedure (CPT 11102) billed at $425 total with $295 insurance adjustment and $130 patient responsibility. The receipt itemizes the office visit and on-site procedure separately.
Receipt Breakdown
What Makes This Receipt Realistic
- • CPT 99214: Level 4 appropriate for a complex ongoing specialist condition
- • $60.00 specialist copay, reflects standard tiered specialist cost-sharing
- • Referral auth number on receipt, required for HMO coverage verification
- • ICD-10 I10: essential hypertension, the most common cardiology diagnosis
- • Math: $183.25 allowed − $123.25 ins paid = $60.00 specialist copay
Frequently Asked Questions
What does this specialist visit receipt show?
This receipt documents a cardiology follow-up at Chicago Heart & Vascular Institute, 680 N. Lake Shore Dr, Chicago, IL 60611. Patient: Thomas W. Patterson. Date of Service: July 8, 2025. CPT 99214: Office Visit, Established Patient, Level 4. ICD-10: I10 (Essential hypertension). Billed: $285.00. Contractual Adjustment: −$101.75. Allowed Amount: $183.25. Insurance Paid (United Healthcare PPO): −$123.25. Specialist Copay: $60.00. Referral Auth #: REF-2025-7391. HSA/FSA Eligible. Balance Due: $0.00.
Why does CPT 99214 cost more than CPT 99213?
CPT 99213 and 99214 both cover established patient office visits, but at different complexity levels. CPT 99213 (Level 3) involves low-complexity medical decision-making, straightforward problems with limited data review. CPT 99214 (Level 4) involves moderate-complexity decision-making, problems with multiple diagnoses, additional work-up data review, or prescription drug management. Specialist visits are often billed at Level 4 because specialists are typically managing complex, established conditions that require more detailed analysis. The higher complexity level justifies a higher billed amount ($285.00 vs $175.00 for a Level 3 visit).
What is a referral authorization number on a specialist receipt?
A referral authorization number (Auth #) is a code issued by the patient's insurance company confirming that the specialist visit was pre-authorized and will be covered. HMO plans require a referral from the primary care physician before specialist visits are covered, without an auth number, the claim may be denied. PPO plans typically do not require referrals, but some specialist services (certain procedures, second opinions) may still require prior authorization. The auth number on the receipt provides the confirmation that the service is covered and gives the patient a reference number if there is a billing dispute.