Health Insurance Calculations – Tricare Participating Provider

There is a video resource that demonstrates a similar scenario.  More information is available to you in Chapter 9 of your text.  Specific tips are:

·         Participating provider receives the full amount listed on the Physician’s Fee Schedule (PFS).

·         Limiting charge = the highest amount the provider can collect from the patient & insurance = PFS x 115%

Fill in the blanks in the following payment situations:

1A

Participating Provider no remaining deductible

Physician’s standard fee                                                        $ 320

TRICARE fee                                                                          $ 235

Patient pays 20%                                                                    $       

TRICARE pays 80%                                                               $       

Provider adjustment (write-off)                                               $       

1B

Participating Provider with remaining deductible

Physician’s standard fee                                                        $320

TRICARE fee                                                                          $235

Patient pays remaining deductible ($100)                              $      

Patient pays 20% remaining charge                                      $      

TRICARE pays 80% remaining charge                                  $      

Provider adjustment (write-off)                                               $