Patient Responsibility Calculator

    Locate your insurance agreements in order to find out what the patient can be billed or use the calculations provided below:

    Note: In rare circumstances, when the primary obligated to accept allowed amount is lower than the Medicare allowed amount, this calculator will not determine the accurate patient responsibility. For more information, see "Determining Secondary Liability".

    Agreement with the primary insurance company Agreement with Medicare Patient can be billed
    Participating Participating Up to the Medicare Fee Schedule
    Non-participating Non-participating Up to the billed amount or limiting charge amount (the smaller of the two amounts)
    Participating Non-participating Up to the primary insurer's allowed amount
    Non-participating Participating Up to the Medicare Fee Schedule

    NOTE: (You are required to use the JH Secondary Liability Calculator,JL Secondary Liability Calculator before using this form.)

    Medicare Participating Providers

    Medicare Fee Schedule:

    Primary Insurance Payment:

    Medicare's Payment:

    Amount Patient Can Be Billed:

    Non-participating with both the primary insurer and Medicare

    Limiting Charge Amount:

    Billed Amount:

    Primary Insurance Payment:

    Medicare's Payment:

    Amount Patient Can Be Billed:

    Non-Participating With Medicare Only

    Primary Insurer's Allowed Amount:

    Primary Insurance Payment:

    Medicare's Payment:

    Amount Patient Can Be Billed: