Calculator Inputs
Example Claim Data Table
| Service date | Service | Billed | Discount | Allowed | Non-covered |
|---|---|---|---|---|---|
| 2026-01-08 | ER facility fee | 2,200.00 | 550.00 | 1,650.00 | 0.00 |
| 2026-01-08 | Physician evaluation | 450.00 | 112.50 | 337.50 | 0.00 |
| 2026-01-08 | X‑ray imaging | 320.00 | 80.00 | 240.00 | 0.00 |
| 2026-01-10 | Follow‑up visit | 180.00 | 45.00 | 135.00 | 25.00 |
| 2026-01-12 | Medication | 95.00 | 0.00 | 95.00 | 15.00 |
Formula Used
How to Use This Calculator
- Enter your billed charges from the provider statement.
- Add an estimated provider discount if you only have billed totals.
- Fill in plan details: deductible remaining, copay, and coinsurance.
- Optionally add out-of-pocket remaining to cap cost share.
- Enter other payments if another payer contributes.
- Click Calculate, then download CSV or PDF as needed.
Claim Inputs That Drive the Estimate
This calculator converts key claim inputs into a payment snapshot. Example: billed charges 2,500 with a 25% discount produce an allowed amount of 1,875. Add non-covered items, such as 40 for supplies, to isolate excluded costs. Use the claim date and currency to keep files consistent across audits and quarters, and payment timing.
From Billed to Allowed and Covered
Billed totals rarely reflect contracted pricing. The discount step moves billed to allowed, then non-covered amounts reduce allowed to eligible covered. In the example, eligible covered becomes 1,835. Recording these layers supports patient explanations, because a 625 write-off can look like “missing” money without context. When discounts are unknown, test 15%, 25%, and 35% to bracket outcomes.
Cost Share Sequence and Out-of-Pocket Control
Cost share is applied in order: deductible, copay, then coinsurance. With deductible remaining 500 and copay 30, the post-copay base is 1,305. At 80% insurer coinsurance, insurer share is 1,044 and member coinsurance is 261. Total member cost share is 791 before any cap. If out-of-pocket remaining is 600, the calculator caps member share at 600 and shifts 191 to the insurer.
Coordination and Remaining Limit Effects
Other payments reduce what this payer contributes. If another payer covers 200, insurer payable is reduced before limits. Limits matter when prior paid is high. With a policy limit of 10,000 and prior paid of 9,500, only 500 remains, so the unpaid due to limit is 344 when net payable is 844. This separation helps distinguish coverage gaps from benefit exhaustion.
Reporting, Auditing, and Scenario Testing
Use CSV or PDF export to document assumptions and share results. Run scenarios by adjusting discounts, coinsurance, deductible remaining, and other payments, then compare final payable and patient responsibility. A practical workflow is low, expected, and high discount runs, keeping plan terms fixed. Store notes for claim references and re-run as bills update.
FAQs
It is billed charges minus the provider discount percentage. It approximates the contracted amount that becomes the starting point for coverage and cost sharing.
If you have an EOB, use its allowed amount instead. Otherwise, test a range (for example 15%, 25%, 35%) and keep the mid-case as your planning estimate.
Non-covered items are excluded from benefits, so they do not receive deductible, copay, or coinsurance treatment. The calculator adds them directly to patient responsibility.
If entered, it caps the member cost share at that remaining amount. Any excess member share is shifted to the insurer portion in the estimate.
Other payments represent contributions from another payer or source. They reduce the insurer payable amount before applying the remaining policy or plan limit.
No. It is an estimate for planning, review, and documentation. Actual adjudication depends on networks, coding, policy rules, and the insurer’s claim processing details.