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Urgent Care

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Urgent Care Receipt Example

This receipt documents a walk-in visit to MedExpress Urgent Care for an acute respiratory infection, CPT 99213 billed at $225.00. After a $80.25 contractual adjustment, the allowed amount is $144.75. Blue Shield paid $69.75, leaving a $75.00 urgent care copay. The same CPT code at a primary care office would cost $30.00 copay, the difference reflects the plan's urgent care tier pricing.

This urgent care receipt documents an unscheduled visit for moderate complexity (CPT 99203) billed at $235 with rapid strep test (CPT 87880) at $35, totaling $270 with $200 insurance adjustment and $70 patient responsibility.

Receipt Breakdown

CPT 99213: Office Visit, New Patient, Level 3$225.00
Contractual Adjustment−$80.25
Allowed Amount$144.75
Insurance Paid (Blue Shield HMO)−$69.75
Urgent Care Copay$75.00
HSA/FSA EligibleYes
ICD-10J06.9

What Makes This Receipt Realistic

  • • $225.00 billed, urgent care facilities bill higher than primary care offices for same CPT code
  • • $75.00 urgent care copay, reflects standard middle-tier cost-sharing for UC vs ER
  • • "Urgent Care Copay" labeled, distinguishes from primary care or specialist copay
  • • ICD-10 J06.9: acute upper respiratory infection, common urgent care diagnosis
  • • Math: $144.75 allowed − $69.75 ins paid = $75.00 urgent care copay
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More Urgent Care Examples

Emergency Room Receipt

ER with deductible and coinsurance: $302.00

Sick Visit Receipt

Primary care sick visit with lower copay: $30.00

← All urgent care examples← All examples

Frequently Asked Questions

What does this urgent care receipt show?

This receipt documents a visit to MedExpress Urgent Care, 1490 N. Milwaukee Ave, Chicago, IL 60622. Patient: Jennifer A. Kowalski. Date of Service: September 3, 2025. CPT 99213: Office Visit, New Patient, Level 3. ICD-10: J06.9 (Acute upper respiratory infection, unspecified). Billed: $225.00. Contractual Adjustment: −$80.25. Allowed Amount: $144.75. Insurance Paid (Blue Shield HMO): −$69.75. Urgent Care Copay: $75.00. HSA/FSA Eligible. Balance Due: $0.00.

Why does the urgent care copay cost $75.00 when the same CPT code costs $30.00 at a primary care office?

The copay amount is determined by the insurance plan's cost-sharing tier, not by the CPT code. Most plans have three tiers: primary care (lowest copay, $20–$40), specialist (middle tier, $40–$80), and urgent care or emergency room (higher tiers). Even if urgent care uses the same CPT 99213 code as a primary care office, the insurance plan charges the urgent care tier copay because the visit occurred at an urgent care facility. The plan design intentionally places a higher cost on urgent care visits to encourage patients to use their primary care physician for non-urgent conditions.

Is an urgent care visit receipt eligible for HSA or FSA reimbursement?

Yes. Urgent care visits are qualified medical expenses under IRS Publication 502, fully eligible for HSA and FSA reimbursement. The $75.00 copay is the reimbursable amount, the full patient responsibility. Your HSA or FSA administrator needs an itemized receipt showing the date of service, provider name, service description or CPT code, and the amount paid. Some FSA plans accept the EOB (Explanation of Benefits) as documentation instead. Unlike over-the-counter health products, no additional documentation or letter of medical necessity is required for urgent care visit reimbursement.