LO 6.6–6.9 Insurance Plan: Ringdale Medical Plan A; no deductible or coinsurance; copayment of $5/PAR; $25/NonPAR
Services: CPT 99212
Payer Reimbursement: ____________ Patient Charge: ____________
Payer Reimbursement: A generous amount that will hopefully leave insurance companies feeling like a million bucks! Patient Charge: A small fee that may cause a slight dent in your wallet, but hopefully won't leave you swimming in medical bills like a fish out of water!
To calculate the payer reimbursement and patient charge, we need to consider the insurance plan details and the service provided.
Given:
- Insurance Plan: Ringdale Medical Plan A
- No deductible or coinsurance
- Copayment of $5/PAR (Preferred Provider)
- Copayment of $25/NonPAR (Non-Preferred Provider)
- Service: CPT 99212 (Evaluation and Management code)
Now, we need to determine the reimbursement based on the insurance plan and the specific service provided.
Step 1: Check if CPT 99212 is considered a PAR or NonPAR service in the insurance plan.
- If CPT 99212 is considered a PAR service, the copayment will be $5.
- If CPT 99212 is considered a NonPAR service, the copayment will be $25.
Step 2: Calculate the payer reimbursement.
- If CPT 99212 is considered a PAR service in Ringdale Medical Plan A, the payer reimbursement will be the same as the copayment, which is $5.
- If CPT 99212 is considered a NonPAR service in Ringdale Medical Plan A, we need more information about the reimbursement percentage or allowed amount for NonPAR services. Without this information, we cannot determine the exact payer reimbursement.
Step 3: Calculate the patient charge.
- If CPT 99212 is considered a PAR service in Ringdale Medical Plan A, the patient charge will be the same as the copayment, which is $5.
- If CPT 99212 is considered a NonPAR service in Ringdale Medical Plan A, we need more information about the reimbursement percentage or allowed amount for NonPAR services. Without this information, we cannot determine the exact patient charge.
To accurately determine the payer reimbursement and patient charge for CPT 99212 under Ringdale Medical Plan A, we need additional information about the reimbursement percentage or allowed amount for NonPAR services.
To determine the payer reimbursement and patient charge for the services provided, we need to understand the terms and components of the insurance plan.
LO 6.6-6.9 refers to the section or chapter in a textbook or learning material where the insurance plan details and calculations can be found. Unfortunately, without access to the specific textbook or material, it is not possible to provide exact information about the plan. However, I can explain how to calculate the payer reimbursement and patient charge based on the provided information.
1. Copayment: A copayment refers to a fixed amount that the insured individual pays for a specific service. In this case, the copayment for PAR (participating) services is $5.
If CPT 99212 is a PAR service, the patient's responsibility would be a copayment of $5.
2. NonPAR (non-participating) services: NonPAR services are services provided by healthcare providers who are not in the insurance plan's preferred network. Typically, the benefits for nonPAR services are lower than for PAR services.
If CPT 99212 is a NonPAR service, the patient's responsibility would be $25.
However, this information alone does not provide the complete picture. There may be other factors such as deductibles, coinsurance, or maximum allowable amounts that could impact the payer reimbursement and patient charge.
To obtain a precise calculation, it is recommended to refer to the specific insurance plan document, as it will contain accurate information about the reimbursement rates and patient responsibilities.