Does Insurance Cover Physicals at Urgent Care?

Physical examinations are a cornerstone of preventive health, allowing for early detection and management of potential health concerns. Urgent care centers have become increasingly popular due to their convenience and accessibility. This leads individuals to question whether their health insurance will cover physicals when conducted at an urgent care facility.

Types of Physical Examinations and General Coverage

Health insurance categorizes physical examinations based on their purpose, which impacts coverage. Annual wellness exams, often called preventive physicals, focus on maintaining overall health and identifying potential issues before symptoms appear. Under the Affordable Care Act (ACA), most private health plans must cover a wide range of preventive services, including annual physicals, without requiring cost-sharing like deductibles, copayments, or coinsurance. For a purely preventive visit, individuals pay nothing out-of-pocket.

However, the scope of the visit determines how it is billed. If a preventive physical transitions into a discussion or treatment for new symptoms or existing chronic conditions, parts of the visit may be reclassified as diagnostic or treatment-related. These diagnostic services are subject to standard plan cost-sharing, such as copays, deductibles, or coinsurance.

Other types of physicals, such as sports physicals, pre-employment physicals, or Department of Transportation (DOT) physicals, are often not considered preventive care under ACA mandates. These specialized physicals are subject to the plan’s standard benefits, meaning they may require a copay or be applied toward a deductible. Urgent care centers often offer these types of physicals, sometimes at a set cash price.

Urgent Care Considerations for Physicals

Seeking a physical examination at an urgent care center introduces specific considerations regarding insurance coverage compared to visiting a primary care physician (PCP). While many urgent care centers accept a wide range of insurance plans for acute care, their billing practices for preventive physicals can differ.

Urgent care facilities may bill differently, sometimes including facility fees in addition to professional service fees. While an urgent care center might be in-network for treating an illness or injury, its services for a preventive physical might not be covered in the same way, or at all, by some insurance plans. The scope of a physical at an urgent care center might also be more limited than one performed by a PCP, which can affect how it is coded and reimbursed by insurers. Urgent care centers often use evaluation and management (E/M) CPT codes for billing.

Verifying Your Coverage and Anticipating Costs

To confirm coverage for a physical at an urgent care center and understand potential costs, verify your benefits. Locate your insurance card, which contains a customer service phone number. Contacting your insurer directly is the most effective way to obtain accurate information. When speaking with a representative, inquire specifically if an annual physical is covered at the particular urgent care facility you plan to visit, providing its full name and address.

Ask about the specific CPT (Current Procedural Terminology) codes that are covered for preventive physicals when performed at an urgent care center. Clarify any copayments, deductibles, or coinsurance amounts that might apply to preventive care at an urgent care facility, especially if any diagnostic services are rendered during the visit. It is also important to ask about any pre-authorization requirements, as some plans may require prior approval for certain services at urgent care centers.

Review your plan’s Summary of Benefits and Coverage (SBC) document. This standardized document outlines covered services, limitations, exclusions, and out-of-pocket expenses for your specific policy. Finally, contact the urgent care center itself to confirm they perform the specific type of physical you need and to understand their billing practices and the CPT codes they commonly use for such services. This helps ensure you are fully informed about potential costs before your visit.