Out-of-Network Balance

Separate recognized cost share from a potential out-of-network balance bill.

Description

An out-of-network balance model separates a recognized patient cost share from billed amounts above the recognized base.

An out-of-network balance model separates a recognized patient cost share from billed amounts above the recognized base. The latter is labeled potential.^[1]

Separate recognized cost share from a potential out-of-network balance bill.

When to use Out-of-Network Balance

Use this tool to separate recognized cost share from a potential out-of-network balance bill.

Prepare the supplied policy terms, dates, assumptions or recorded indicators requested. Keep monetary amounts on one currency basis and select the applicable thresholds separately.

How to use Out-of-Network Balance and understand its results

Prepare the supplied policy terms, dates, assumptions or recorded indicators requested. Keep monetary amounts on one currency basis and select the applicable thresholds separately.
Enter billedCharge, recognizedAmount, patientCostSharePercent, patientPaymentsMade using the field table and calculation rules, then run the tool.
Read allowedPatientCostShare, potentialBalanceBill, patientRefundDue, providerPaymentGap. The explanation below defines the units, signs, ordering and any flags or placeholder values.
If the tool reports an input issue, correct the values and run it again. Apply the stated assumptions when interpreting a successfully returned result.

Input field	Meaning	Value type; see rules below	Requirement
billedCharge	Out-of-network billed charge	number; minimum: 0	Required
recognizedAmount	Recognized amount	number; minimum: 0	Required
patientCostSharePercent	Patient cost share (%)	number; minimum: 0; maximum: 100	Required
patientPaymentsMade	Patient payments made	number; minimum: 0	Required

Enter nonnegative billed/recognized/paid amounts and percentage 0–100. Return recognized share, potential balance, refund estimate and provider gap equal to the potential balance. Recognized amount need not be below billed charge.

costShare=recognized×percent/100; potential=max(0,billed−recognized); refund=max(0,paid−costShare)

Units, indexing, boundary conditions and exceptional cases are defined in the calculation rules above.

Output field	Meaning	Value type
allowedPatientCostShare	Allowed patient cost share	number; minimum: 0
potentialBalanceBill	Potential balance bill	number; minimum: 0
patientRefundDue	Potential patient refund	number; minimum: 0
providerPaymentGap	Billed charge less recognized amount	number; minimum: 0

json

{
  "input": {
    "billedCharge": 1000,
    "recognizedAmount": 600,
    "patientCostSharePercent": 20,
    "patientPaymentsMade": 200
  },
  "output": {
    "allowedPatientCostShare": 120,
    "potentialBalanceBill": 400,
    "patientRefundDue": 80,
    "providerPaymentGap": 400
  }
}

Limitations and assumptions

No surprise-billing protections, enforceability, payment allocation or actual refund obligation is determined.

Numeric inputs must be finite. Follow the calculation-specific rules for overflow, underflow and exceptional cases. Missing required fields, extra fields, wrong value types and violations of the calculation rules are input errors.

Alternative or Complementary methods

Use Family Deductible Progress: Track embedded individual expenses toward a family deductible. For a complementary task, use Coverage Affordability: Test coverage affordability using a caller-supplied income percentage.

References

Out-of-Network Balance — tool.io

Similar or alternative tools

Family Deductible Progress
Track embedded individual expenses toward a family deductible.
Coverage Affordability
Test coverage affordability using a caller-supplied income percentage.