For a nonPAR who bills a submitted charge of $650, which amount represents the limiting charge as calculated?

In health insurance billing, particularly regarding non-participating providers (nonPARs), the concept of a limiting charge is crucial for understanding how much can be billed to a patient. For nonPARs, the limiting charge is determined based on a percentage of the allowed amount set by Medicare or other insurance providers.

When calculating the limiting charge, the amount typically represents 115% of the Medicare-approved amount for that service. This means that the nonPAR cannot charge more than this limit. For the charge of $650 submitted by the nonPAR, the calculation to reach the limiting charge would involve knowing the allowed amount first and then applying the limiting percentage.

The answer of $491.63 signifies that this is the cap on how much the provider can bill a patient for that service, adhering to the established rules. This amount reflects the proper percentage applied to the allowed value by the billing guidelines relevant to nonPARs.

In contrast, other values listed do not align with the standard calculation for the limiting charge. For instance, the original charge of $650 exceeds what can be billed for that service according to the guidelines, and the other figures either do not meet the limiting charge calculation or exceed permissible billing amounts. This understanding is essential for compliance with Medicare