Patient cost estimate worksheet
A downloadable CSV structure for turning an eligibility and benefit response into an honest patient cost estimate — without embedding patient data in the example.
CSV · Reviewed 2026-07-18
Download and use
The download contains headings and blank rows only. The examples below use fictional operational references so you can see the intended structure without copying patient data.
Column guide
Internal reference
Use a non-PHI internal work reference.
Payer
Payer or plan name.
Plan
The specific plan or product to be billed.
Service description
A non-clinical description of the planned service.
Allowed amount basis
What the estimate is built on — contracted rate or fee schedule, not the billed charge.
Deductible remaining
Remaining deductible from the benefit response.
Copay or coinsurance
The cost-share terms that apply to the service.
Out-of-pocket max remaining
Remaining out-of-pocket maximum, which can cap the estimate.
Estimated patient share
The estimate, labeled as an estimate. Example values only.
Basis and date
The response date and any payer reference the estimate rests on.
Fictional example
| Internal reference | Payer | Plan | Service description | Allowed amount basis | Deductible remaining | Copay or coinsurance | Out-of-pocket max remaining | Estimated patient share | Basis and date |
|---|---|---|---|---|---|---|---|---|---|
| EST-001 | Example payer | Example PPO | Office visit | Contracted rate | Met | Copay only | Not reached | Estimate: copay per benefit response | Response dated 2026-07-15 |
| EST-002 | Example payer | Example HDHP | Outpatient procedure | Contracted rate | Partially remaining | Deductible then coinsurance | Partially remaining | Estimate: deductible balance plus coinsurance, capped at OOP max | Response dated 2026-07-16 |
Working instructions
- 1Build the estimate from the plan's allowed amount — the contracted rate or fee schedule — not the billed charge.
- 2Treat every figure as an estimate and label it as one; the final patient responsibility is set only when the claim adjudicates.
- 3Confirm deductible, cost share, and out-of-pocket status from the payer's current benefit response before relying on the worksheet.
- 4Do not enter patient names, identifiers, diagnoses, or claim details in an unsecured copy of this file; keep the benefit response in the approved secured system.