HSA 100 Basic Calculation Assignment (In-Network) Name: Policy Information Deductible: $2,500.00 Copayments: (Only the services listed below are copayments - All others services are coinsurance) In-Network Primary Care Physician Office Visit: $25.00 In-Network Specialist Physician Office Visit: $35.00 In-Network Emergency Department Visits: $500.00 In-Network Outpatient Therapy Visit: $50.00 Urgent Care Center Visit: $75.00 Outpatient Surgery Center $750.00 Coinsurance: 80/20% (All other healthcare services are paid under coinsurance) Maximum Out-Of-Pocket (OOP): $4,500.00 1. Susie went to her pediatrician. The allowable for the pediatrician was $89.54. How will the payment to physician take place? Patient's Annual Year-to-Date Summary Prior to This Encounter: Toward Deductible: $475.00 Remaining Maximum OOP: $3,025.00 Total Insurance Consideration Amount Insurance Allowance (Total) Running Balance $89.54 Deductible (Patient) $0 $89.54 Deductible (Patient) $0 Styles $89.54 Coinsurance/Copayment (Patient) $25.00 $64.54 Insurance Payment $64.54 $0 John went to his family practice physician (Dr. Johnson). The allowable is $123.45. How will the payment to Dr. Johnson take place? Patient's Annual Year-to-Date Summary Prior to This Encounter: Toward Deductible: $2,385.45 Remaining Maximum OOP: $4,156.98 Total Insurance Consideration Amount Running Balance Insurance Allowance (Total) $ Deductible (Patient) $ Coinsurance/Copayment (Patient) $ $ 3. Wanda went to the emergency department. The allowed payment for hospital is $6,285.55. How will the payment to the hospital take place? Patient's Annual Year-to-Date Summary Prior to This Encounter: Toward Deductible: $2,400.00 Remaining Maximum OOP: $1,785.22 Total Insurance Consideration Amount Running Balance Insurance Allowance (Total) $ Deductible (Patient) $ $ Coinsurance/Copayment (Patient) $ $ $ $ Insurance Payment $ $ Michael had a 9-day stay at the local hospital. The allowable was $145,333.69. How will the payment to the hospital take place? Patient's Annual Year-to-Date Summary Prior to This Encounter: Toward Deductible: $2,500.00 Remaining Maximum OOP: $3,274.65 Total Insurance Consideration Amount Running Balance Insurance Allowance (Total) $145,333.69 Deductible (Patient) $0 $145,333.69 Coinsurance/Copayment (Patient) $3,274.65 $142,059.04 Insurance Payment $142,059.04 $0 Joe went to a urologist. The allowable for this visit was $98.75. How will the payment to the urologist take place? Patient's Annual Year-to-Date Summary Prior to This Encounter: Toward Deductible: $2,500.00 Remaining Maximum OOP: $31.12 Total Insurance Consideration Amount Running Balance Insurance Allowance (Total) $ Deductible Ipatient) PRI HSA 100 Basic Calculation Assignment (In-Network) Name: Policy Information Deductible: $2,500.00 Copayments: (Only the services listed below are copayments - All others services are coinsurance) In-Network Primary Care Physician Office Visit: $25.00 In-Network Specialist Physician Office Visit: $35.00 In-Network Emergency Department Visits: $500.00 In-Network Outpatient Therapy Visit: $50.00 Urgent Care Center Visit: $75.00 Outpatient Surgery Center $750.00 Coinsurance: 80/20% (All other healthcare services are paid under coinsurance) Maximum Out-Of-Pocket (OOP): $4,500.00 1. Susie went to her pediatrician. The allowable for the pediatrician was $89.54. How will the payment to physician take place? Patient's Annual Year-to-Date Summary Prior to This Encounter: Toward Deductible: $475.00 Remaining Maximum OOP: $3,025.00 Total Insurance Consideration Amount Insurance Allowance (Total) Running Balance $89.54 Deductible (Patient) $0 $89.54 Deductible (Patient) $0 Styles $89.54 Coinsurance/Copayment (Patient) $25.00 $64.54 Insurance Payment $64.54 $0 John went to his family practice physician (Dr. Johnson). The allowable is $123.45. How will the payment to Dr. Johnson take place? Patient's Annual Year-to-Date Summary Prior to This Encounter: Toward Deductible: $2,385.45 Remaining Maximum OOP: $4,156.98 Total Insurance Consideration Amount Running Balance Insurance Allowance (Total) $ Deductible (Patient) $ Coinsurance/Copayment (Patient) $ $ 3. Wanda went to the emergency department. The allowed payment for hospital is $6,285.55. How will the payment to the hospital take place? Patient's Annual Year-to-Date Summary Prior to This Encounter: Toward Deductible: $2,400.00 Remaining Maximum OOP: $1,785.22 Total Insurance Consideration Amount Running Balance Insurance Allowance (Total) $ Deductible (Patient) $ $ Coinsurance/Copayment (Patient) $ $ $ $ Insurance Payment $ $ Michael had a 9-day stay at the local hospital. The allowable was $145,333.69. How will the payment to the hospital take place? Patient's Annual Year-to-Date Summary Prior to This Encounter: Toward Deductible: $2,500.00 Remaining Maximum OOP: $3,274.65 Total Insurance Consideration Amount Running Balance Insurance Allowance (Total) $145,333.69 Deductible (Patient) $0 $145,333.69 Coinsurance/Copayment (Patient) $3,274.65 $142,059.04 Insurance Payment $142,059.04 $0 Joe went to a urologist. The allowable for this visit was $98.75. How will the payment to the urologist take place? Patient's Annual Year-to-Date Summary Prior to This Encounter: Toward Deductible: $2,500.00 Remaining Maximum OOP: $31.12 Total Insurance Consideration Amount Running Balance Insurance Allowance (Total) $ Deductible Ipatient) PRI