Telehealth Claim Cost Calculator

• Extra minutes = max(0, visit minutes − included minutes).
• Time component = base fee + (extra minutes × per-minute rate).
• Professional = time component × multipliers (type × tier × credential × patient × complexity).
• Covered billed subtotal = professional + selected per-visit fees + overhead + flag surcharges.
• Covered billed total = (covered subtotal − discount) + tax.
• Total billed = covered billed total + non-covered amount.
• Allowed = covered billed total × allowed factor × plan scaling.
• Member share applies deductible, then copay, then coinsurance on allowed, capped by out-of-pocket remaining.
• Balance billing (OON) = (covered billed total − allowed) × balance billing %.
• Expected values blend approved vs denied outcomes using denial risk and appeal success.

1. Select plan type, network status, and visit details.
2. Enter minutes, base fee, and any service or administrative fees.
3. Fill in benefits: copay, coinsurance, deductible remaining, and out-of-pocket remaining.
4. Set allowed factors, balance billing percent, and denial inputs for realistic scenarios.
5. Optionally add secondary coverage, assistance, and payment terms for a full estimate.
6. Press calculate. Export CSV or PDF for recordkeeping.

Claim cost components and structure

Telehealth claims often blend professional time, technology, and administrative overhead. This calculator builds a covered billed amount from a base fee plus per-minute charges beyond included minutes. It then adds platform, documentation, processing, and optional services like interpreter support or remote monitoring supplies. Each visit is priced consistently, then multiplied by the number of visits for rollups. For better forecasting.

Network status and allowed amount modeling

Payers rarely reimburse the full billed amount. The model converts covered billed charges to an allowed amount using an in-network discount or an out-of-network allowed percentage. Plan type can further scale the allowed estimate to reflect typical reimbursement patterns. The contractual adjustment equals covered billed minus allowed, and out-of-network balance billing can shift part of that adjustment to the member.

Member responsibility and benefit sequencing

For insured plans, the calculator applies deductible first, then copay, then coinsurance to the remaining allowed amount. An out-of-pocket remaining limit caps the member’s covered share and automatically shifts any excess to the insurer portion. Non-covered items stay member-paid and are not capped, which helps simulate items excluded by benefit design or policy rules.

Denial risk, quality, and expected cost

Claims can be denied for missing modifiers, referral rules, or weak documentation. The calculator estimates an effective denial probability from a base risk, coding quality score, and missing-information flags. Expected patient cost blends the approved scenario with a denied scenario that includes full billed amounts and an appeal fee. This creates a practical budget range instead of a single optimistic number.

Scenario comparison and operational planning

Use the inputs to compare visit types, provider tiers, and complexity levels side by side. Adjust minutes, discounts, and taxes to match your charge master, then test best-case and worst-case denial assumptions. The chart summarizes how dollars split across patient, insurer, and adjustments, while CSV and PDF exports support audits, quotes, and internal review.

1) What does “allowed amount” represent here?

It is the estimated reimbursable amount for covered charges after applying network and plan assumptions. It is not a guarantee and can differ from the final payer remittance.

2) How is patient responsibility calculated?

For insured plans, deductible is applied first, then copay, then coinsurance. The covered member share is capped by the out-of-pocket remaining value in the model.

3) What happens when the claim is denied?

The expected value section blends an approved outcome with a denied outcome. Denials assume the patient is billed the full total plus an appeal fee, with optional appeal success.

4) When should I use balance billing inputs?

Use balance billing when the provider is out-of-network and the plan allows billing the member for part of the covered adjustment. Keep it at zero for in-network scenarios.

5) How do secondary coverage and assistance discounts work?

Secondary coverage reduces only the covered member share. Assistance discount applies to the patient’s combined responsibility, including non-covered and balance amounts, after secondary is applied.

6) Can I export results for audits or estimates?

Yes. Use the CSV export for spreadsheets and the PDF export for sharing. Exports include key inputs, totals, and per-visit metrics used in the calculation.