Estimate My Cost® enables you to create your own accurate out-of-pocket price estimates anytime, anywhere.
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General
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Let's get started!
Please select an option below.
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Visit Information
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Please complete the information below.
(*) indicates a required field.
FACILITY*
Your preferred location of healthcare service.
VISIT TYPE*
The patient's type of healthcare service based upon the kind of care needed.
PROCEDURE CATEGORY*
Make a selection to see a list of associated tests and procedures
The broad category or department classification that the procedure or test may be listed under.
PROCEDURE(S):
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What type of procedure would you like to estimate?
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Patient Information
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Please complete the information below. (*) indicates a required field.
FIRST NAME*
The first name of the patient.
LAST NAME*
The last name of the patient.
DATE OF BIRTH*
GENDER*
FEMALE
MALE
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Insurance Information
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Please complete the information below. (*) indicates a required field.
ARE YOU INSURED*
YES
NO
INSURANCE NAME*
The policy holder's health insurance plan as listed with the healthcare facility.
MEMBER ID / POLICY NUMBER*
The member or policy identification number found on the card issued by the health insurance plan.
GROUP NUMBER
The group number found on the card issued by the health insurance plan. This group number identifies the specific benefits associated with the patient's employer's health insurance plan. Not all health insurance plans have a group number.
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PATIENT'S RELATIONSHIP TO THE POLICY HOLDER*
SELF
SPOUSE
CHILD
OTHER
POLICY HOLDER'S FIRST NAME*
POLICY HOLDER'S LAST NAME*
POLICY HOLDER'S DATE OF BIRTH*
GENDER*
FEMALE
MALE
Coverage
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To edit your coverage amounts select the amount or pencil icon.
Note: Estimate accuracy may be impacted by values entered in this screen.
COPAY
Edit Copay
A fixed amount (for example, $15) you pay each time for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.
DEDUCTIBLE
Edit Deductible
The amount you owe for covered health care services before your health insurance plan begins to pay. For example, if your deductible is $1,000, your plan won't pay anything until you've paid $1,000 annually for covered services. Some plans pay for certain health care services before you've met your deductible.
CO-INSURANCE
Edit Co-Insurance
Your share of the costs of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service. You pay coinsurance after you've met your deductible. For example, if the health insurance plan's allowed amount for an office visit is $100 and you've met your deductible, your 20% coinsurance payment would be $20. The health insurance plan pays the rest.
CO-INSURANCE MAX
Edit Co-Insurance Max
The maximum amount of coinsurance a patient can be required to pay.
OUT-OF-POCKET MAXIMUM
Edit Out-Of-Pocket Maximum
The most you'll have to pay for covered services in a policy period (usually one year). After you reach this amount, your health plan will pay 100% for covered essential health benefits.
OUT-OF-POCKET REMAINING
Edit Out-Of-Pocket Remaining
The amount remaining towards reaching your maximum out-of-pocket amount.
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Payment Estimate
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The following is an estimate of charges based upon the information you provided. Please save your reference number for future access.
PATIENT NAME:
UNKNOWN
Estimate prepared on:
UNKNOWN
EST. #:
N/A
Diagnosis Code:
Not Provided
Patient Group:
Not Provided
Service:
Not Provided
Facility:
UNKNOWN
UNKNOWN
NPI #:
UNKNOWN
Tax ID:
UNKNOWN
INSURANCE COVERAGE
The policy holder's health insurance plan as listed with the healthcare facility.
Insurance Name
N/A
The amount remaining that you will have to pay annually for your healthcare before the health insurance pays anything.
Remaining Deductible
N/A
The amount remaining towards reaching your maximum out-of-pocket amount.
Out-of-Pocket Remaining
N/A
A fixed amount (for example, $15) you pay each time for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.
Copay
N/A
The percentage of costs of a covered health care service you pay after you've paid your deductible and the total amount of coinsurance that you will owe of covered expenses for a calendar year.
Co-Insurance % / Max
N/A
/
N/A
HOSPITAL SERVICE CHARGES
The listing of procedures to be performed.
Procedures:
The estimated charge for an individual item or service that is reflected on a hospital's chargemaster, absent any discounts.
Total Estimated Gross Charge
$0.00
The amount a health care provider writes off or adjusts from a patient's balance in accordance with agreement with the health insurance plan covering that patient.
Total Contracted Discount
$0.00
The charge that a hospital has negotiated with a third party payer for an item or service. Or if self pay, the discounted cash price that applies to an individual who pays cash, or cash equivalent, for a hospital item or service.
Payer-Specific Negotiated Charge
$0.00
The amount your health insurance plan will pay your health care provider.
Total Insurance Portion
$0.00
Total Estimated Patient Portion
$0.00
PATIENT PORTION BREAKDOWN
View Detailed Breakdown
Your primary insurance provider, or self, who pays your healthcare provider directly for medical expenses.
Coverage Level
N/A
A fixed amount (for example, $15) you pay each time for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.
Copay
N/A
The amount you owe for covered health care services before your health insurance plan begins to pay. For example, if your deductible is $1,000, your plan won't pay anything until you've paid $1,000 for covered services. Some plans pay for certain health care services before you've met your deductible.
Deductible
N/A
Your share of the costs of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service. You pay coinsurance after you've met your deductible. For example, if the health insurance plan's allowed amount for an office visit is $100 and you've met your deductible, your 20% coinsurance payment would be $20. The health insurance plan pays the rest.
Co-Insurance
N/A
The amount remaining towards reaching your maximum out-of-pocket amount.
Out-of-Pocket Excess
N/A
Total Patient Coverage Portion
$0.00
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FIRST NAME*
LAST NAME*
DATE OF BIRTH*
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